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�^�°RKERS�°^^�N�n°N°E�aR^T�°N APPLICATION FOR PLUMBING PERMIT �
I hereby aff�rm�hai I hove o cer�ificdre of conaenf fo self �yp�y�p
insure,or a certifim�e of Workers'Compensalion InsUranCe, CE 817 BEY.IOJ81) � .
or a cn'ied co Ihereo�ec.3800, D. .) � �
COUNTY OF COS ANGELES BUILDING AND SAFETY
P❑olicy . Company . . '
Cenitied copy if here6y fur ( i
. fOR APPUUWT TO FIlL IN(PRMT OR�YPE) AD�� -� � r. . S
�CeNified copy is filed with fh c unry� �i c-� . . . .
tio d ent. t M1Ana[a flXNREORIIFM � � lOC'JLL�Tv i
Oo}a � Appli�vnt �. . . .. �NATER CL05ET ,
CE FICATE OF F.7�MPT10 �FROM WORKERY BA1H 1U9 � . . ��. �- . . . . �
COMPENSA710N lN URANCE �� OWrffR ,�
(ihis s.ctlen nNd not FN eo�hpt�»d 1�•Mirwork�fnvolwd by � �
tha pormiT Is For nns hondred dellan(f100)e►ists.) �qvATpRy n q�u !
I certify�hv.r in�he perfvrmancs of�he work frn wRich this �S�rn: � . . � clrt . . . . �ni0. . a �--
— permit i�y isaued.1 s)wll nof amPloyamY persRn in any erypnnar
ao cs b becpme subjen�o�he Workels'Ccmpenmtion taws. _ ORF1wn5NFR ' �
C�IR'^C'°R V, It.
DOfC �PPlicanf - CtOTM4 WASMFN A�� L �'
NOTKE TO APPLIC,AIVT: 14, oher mok�n �hia CerrtRca�e c� �
9 SWIhMNNGP00l RECEPfOR - -
Exemption, yon should becoma sub'lect�ro the Wrnkers' ''
CompCnaotion prorisipm of Ihe luhar CadO.�ou mvSt fonh- � �pyy�.��INKIFR 5�51FM C�iv. TEt. '
with tomply with wch provisiom m 7hi�perm�t shall be STATE UC.
deqmed revoked. - � , wqiElt HEAiEtt t���. �S' ,
IICENSEO CANiRACTpRS DECLARAiION . a� ' o�SrRici ta0. er
I hmeby affirm tho�I om licensed undflr proviaiona of�Chopter 9 GAS SrSTEM OUTtETS - .
�commencing -th SacKon 7('1pq)of Dirisi0n 3 of rha�usiness pU7�Ff5pYER Y :.
and Profenions Code,and my license�s in full force o�u)eftecL S PER SVSTEM fINlLL a' �
'u � VALIDATION � �
ontE .y� � u j
ticen u r Lic.Closs
�J�{ fIN � �
"CdrltAct r �� Dote . . BV�`:li. i� V ;
� I pm e�empf under Sec . - d �
�
e.ar.c.(o.�b�s reaso� plan check fae � Z '
�e� PLUMBING PERMIT I$$UING FEE f �
SipnMwe
. TOTAi FEE �
. . Plan check applicant '
SIIVGLE fAMIIY - I
HOME ONRJER-BUIIDER pECIARATION Name - � � �� .3�G-A
I hereby atf irm 1M!I cm exempt{rom tha ConRactor's Liceme �fe� . . - � ,, j
law for the following rooton(SeNion 703t.5,eusiness and � �, .;. � �a 1
Professions Coda): Ci�y Tel.No. �
❑ I,m owner of rha prope.ry,w�ll do the wo�k ond+he � - � •��3 Q 5�
shadure is no�iNendad or offered fo�wla(Sec�ion � •
7044.Busines�and Professiooa Code). . . . ► • •,�3 Q 5 0 c=i
CONSiRUGT10N LENDMG AGENCY 0 2 O 3—8 4
I hereby off irm�hat there is a tonstruction lending agenty for
H�e performonce of the wo/k for which rhis permir is issoed . i
(Sec.3097.C��.C.). . - �
�
Lendar's Name - � '
Lendq{i Address � . . . . . . . . . .
cenify�hot I hove reod th�s opplicaiion and alafe ihai the ► . �
a e info(�nolion's croroU.I ogroe to camply wilh oll Coun�y ,
o inunces te laws regubtin9 Plumbing,ved hereby
horize ro re ta�ives ot.this Count �o en�er upon the . . . . �
b -menY n roperty fa inspecuon Dur . . .
SEE REVERSE FOR EXPLANATORY LANGUAGE .
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