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1750A
� . IVORKERS'COMPF,NSATION�ECI.ARAT70N �swcsia �PPLI0.i�9TIO1� rOR P��M��IN(� F-RM�T �-� � [hereby affirm that I have a rertificate of consenbto self ce en(z-aoi `�+ �-- ��-�{ 5 tiisure,or a cerCificafe of Workers'��ompensation Insurance,or �- �� g a certified copy Ihereof(Sec.3800,Lah.C-) � � � COUNTY OF LOS ANGE LES BUI LDtNG AND SAFETY YolieY�o. ^- ��^� Compan} •.`ry� �.�.�>. �.'��-. 9 — �� ❑ C',ertified copy is hereby funlished FOR APPLICANT TO FILL IN(PRINT OR TYPE) B111�D�NG � � � � ADORESS t ..,+) ��..i;. ..v ;^7: . i � Certifi2d copy is fi3ed w th{he �ount3e,b.�iiding.in5pec['on Nl/MBER FIXTUftE OR ITEM • FEE � ,,,,,;n�2^ � LOCALITY lagr� .... — . `�FAYIr a'�t WATER CIOSET 7 Da e "�' Apptica . � NEAREST - � � .� �� .• . 8A7H TUB i CROSS ST 1 ��?`-!` � 7 'i`�_ _..__ . 1 CERTIFICATE Ot EX.E:�IPTIC1Iv �ROM WQRKERS' - � � . GOMPF.NSAitON INSURANCE SHOWER i � OWNER � i ,, ,� " ' . _—. _.__ LAVATORY MAIL � �. � (This section necd noC 6e complated if the woxk imalved ; , aooREss � ��•a� f7�/,.l ��' } lzy the permit is for one himdxed dotlazs ($100)or less.) � � -�-��� � �,' r��� � $ . � SIIVK I CITY TEL.NO�_ , _,�t'(' ...'1 � � .. ._ -__.._ . I certify that in the per£nrmanee of the work for which this �ISHWASHER i �`" permit is issued,I shall not en�ploy any person in any manncr , CONTRACTOR .,)_ '. :�r�1. � . � ao as to become subject to the Wocknrs'Compensatioq Laws. _ CLOTHES WASHER qDDRES5j 7t3�n n � , 4Z}_*� � �. _., ' _.— -�-.__._ ,� Dg}g�� Applicant ._ ,SN/IA4MING POOL RECEPTOR I � � '7^.s '�a�' �. � q 'iO;ICE'CO,4Pi'LICANT:If.after making thls CerTificate oE � , CITY .,. . . �..,,, .- . TEL.NO '- - . � j ixemption, you shvuld "become sub;ect to the Workers' LAWN 5PRINKLEii SYSTEM � STATE � i'r,�'�Ej�] LIC. ;1-�s� � � h Compe�sation provisions of tfie Labor Code,you must Forth- —���- -"—��� , ,LICENSE NO. - CLASS ° �vi�h comp!}• �.a�ith such provisions or t;:ss p�:nii shail he WATER HEA7ER . � dP.emed re��oiicd. ' - �— � �. _ DISTRICT NO. PROCESSED$Y � . iGASSYSTEM OUTLETS �. �/ .�9� "� 3CE.i�SBDc.ONTRACTORSDECLARATION —�p�T�ErSOVER ��� � ✓�)�l"` I h eb} ff�m that I am licenaed under provisinns of ChapYer 5 PER SYSTEM 4 (��m ei� ng �m Sectioa�ODD)of pivision 3 af Yhe Ausi �.�- �.,.'�, �1���, FINA� ����� �����A.���� � nas;end Pcofess o t� Code,and my 3ice;ise is ih full focce and _ DATE �,_ zffeet � FINAI. i��r.3 �.. � Liconse Number � ���� Lic.Class _ BY _ n' `�str° ..ts t� - . 5 � 7+ ; ConcraUnr Date_. �=�'�- t�, � � � I am cxe t from t c h-��cing reyuirements as I am a P�an Ch2Ck f88__ _ � ' � iirensed architect o: a registered professional engineer p�UM61NG PFRMIT ISSUING FEE$ ' <� � � � �c4iag �n my pmf.ss�onai capaci:y(Seec'sort 7051,Bus- -J � _ i r � fl, mess aad Professions Code). FOTAL FEE _� ,j� Lic.or Reg No. Da[e _ Plan check applicant � � -�� � . _ - - �. r�,/ j_: r HOA1E 0:7NtiR-BUILBRR DECLARATLON Namn .��� � n , ._— . .., ;". � � Atldre '!� '�t,� . n S ..s�J � . rv� . I hereby afficm that 7 am azempt from fhe Cantractor's �—� - License I,a�v for ffie foltn�virg reason{Se�tion.7031.5, Busi- Cirµ;;, �" - ,a� r1_7 Tel.No. -�o�����.�7`r' .. � - . �� ness and Professions Code): � � I,as owner nf the prope[ty,em exclUslvety contracting - 'f�L 1���t _ - ` with licensed contractncs to cmistruct the ptuject : � � (Section 704a,Business and Urofessions Code}. . . �i - CON5�1 RUCTION LRNDING RG�NCY . - � � . i i hexebY �fflrm [ha? tl:er� is a cor.straction len@ing agency � . . � 4'or the perfmmance of tlie work for which this permit is - �. - - t. issued(Sec.3097,Civ.C.). . i I,endeYs Name ___. � � . { Lendcr's Addrzss - t� I certify thaY I f��ve read this applicatimi snd stflte that the - �-� abc�ve information is co-recS.I agree to comply witli all County _ SEF.REV N RSE FOR F.XPLANATORY LANGUAGE - ' - , - ord�nances and State laws regulntio� Plumbing, and hereby authonze representatives of @us Coanty Co e�ter upon the - -' _ � � - � abuve-rnentioned property feriospection purposea. - . � �:.., '/'�'��j" � . - j � . . . ; S�gn ture f Yerm�� �� Date'����� .. _ _ . . . j _ _ ,�Z - -n C � � S,C) L� �1 C � Z ��i >, ,.c Oi)>�A �O �I ��O r in , � tn�cn I,- �, "'�uCi � . i�. .j"!c�a ��<i-n;� m,D r'i� < mI�,D ml�iY �' � _.. : _ .. , �D �O � �7�mi-�i �',,� if�" �t''�.0� . �r O '-_�j i m I � �I� D � C � ;S I� CIA � �Ir y n ��a,m I Iz�Olcn r C-� � I�n'�� --�� � I��� ��I—',� � � I �} i � . fl�� � I � � o -� � , I , I I;A� I b z�l Iy�I I� i 1 r rn � � Z I l o C�� ' �i � -� . . ���. � � � � . - I f � � D'�"' i h �,. � ; , . : ' ' ',� ° �1 'i I 'z .- _ ._J ,. .. 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