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"'°"KE�•�°"`�"�,T'°"°�,�"T'°" ; APPUCATION FOR PL.UMBING PERMIT
I hareby affirm ihat I hove a certificab of conxn�to self ' �y�yy�p , � �
_ iosure,or a cenifica�e of Workers'Compemo�ion Mluronce, � CE et7(REV.t0i81) - � � '� � - -
o.a«���r�ed opy thereof L«.aeo tob.c.) G� ', COUNTY OF LOS ANGELES j BUILDING AND SAFETY '
a`""��`�°p°°°Y ,
Certified copy is hereby fumished. -
�./� FOR ADPIIGWT TO FIU IN(7RIM OR TWEJ 8��� � � !
I7CI Certi{ied eopy is filed wi�h the county building inspec- �� �
%� tiondepartment. NUMBER � flXTUREORITEM p FEE " ±
10 �� ��4�A�.l� LOGtItt �
�alte Applitonl WAfER C,lfnEf .. .. NE1lRE5T , _ �
CERTIFICAiE Of EXEMPRION FROM WORK BAiH TVe � �. �.
j
� COMVENSA710N INSURANCE . . . pyy�yER .
(Thts s�Nton need eof be wrhpteNd tf tlri work ImeMd 6y SHOWER - a
�tha p�rmlf Is ier on�hvndred�.dollars(St00)or la��.) -. ' �qyq�v - �� .'�(� � � �� a� 1
I cerli/y that.in the perfomance of tha wwk fOr wNith tbis !
permit is issued,I si�all not employ any peraon In cny mpnner � � . ���_ �El.NO. ( . �
– ao as to bewme subject ro the Workeri Compenwtivn laws. � � � ,
. . . . � OISHWASHER CONIRACTOR , � . e � . �
Date �pplicAnt .. . C10THES WASMER ADORE55 � �FO�I�� �.1' I
NOTICE TO APRIUM: If, ahx making��his Cerrificaro of
Exemp�ion, you ahould-become subjacl fo the Workers' $W���P���� i
Compemation provieiom of�he labor Code,yw m�si fonh• � � m'�' � - `
�wilh compiy wieh cuch provisionc or Ihis permit shail 6e . ���NKtER SYS7EM G/ j
deemed reroked. - wnmt HEn7Elt �tl�1�115E No. �O 10�– LK. �, i
UCENSED CONTRACTOR$OKIARAt101V � . . ` OUSiWCi vRO�n sr
!hae6y afEirm tho�I om licen�ed uRd�provisions p1 Chapter 9 � ��� �T� .. . ;
(cpmmenci�with Section 70()p)pf.pivisi4n 3 qi the 9usiness q,�7tEigpVER . d �
om!ProfeRions Code,and my license ia in ivll force ard S�ER�SYSiFM ��� .
//�'Q�� �_ �� VAl10ATION V 3
License NumbeTl ��c.Class� -
�y� �,�,p� p�` . � �� .. . OC i
Contron�—�—N�t`��� �vo'e �i�a'��uJ _ . . _ . B� . V �
I ❑ I am exemp�under Sec. � - .. _ . . . ��( .6�r �fL x �–"//"'�7 � y�3�
� � B.SP.C.for thia reason " � _�j
Plcn CheGk fee .
�► �� �.-�/¢� ,
� � Date: p�U/ggING VERMiT�SSUWG FEE S �����'�N, i
'���� TOTAL FEE _ �/r���Q'0 . j�',�o ..• "� �
J��^ D'� ;r,,r �
SINGLE PAMILY Plon check appliwnt � . � (,o� .9
HOME OWNER-BUIIDER DEUARATION Name � . `,(�, j��_
I he�eby affirm�hal I om exempf from the Contracror a License � - - . . • y ^ - i
Law for the following reason�Sec�ion 7031.5.Business and "��0� � � � . � .�� ��,� [ –;�(� i
Professions Cade): City Tel.No. - ' �
� I,as owner of the proper�y,will do the work and�he � . - ;
ehucfure is not intanded or offered for tpie(Secfion . . � �' � i
� 7044.Busirross ard Profassions Code). . . . . . .
i
CONSTRUCTIpN IENDMG AGENCY - . ... .. . . �
� I hxeby affirm�ha1 there is a conshuclion lendi�agenry fa �
�� the parformance of tha work for whieh this permit is issued , _ . . , _ . .
(Sec.3097,Civ.C..).
i
r Lander's Name � . ' - . . . ;
I !
! lendeis Addren �
� I cehify�hat I hove read ehis opplication ond state that the . ,
a6ove in4amc8on is corcect.I agree to comply with all County . . . .. . . -.-- ' . . . . •
� �� ordinanca and State lawa regula�ing Plumbing,and hereby j
authorize r r ives of this Coumy ro enter upon tha�
obove-ment ned pr �fw inspection purpm . j
c � SEE REVERSE FOR EXPLANATORY LANGUAGE �
� giwture rmifle 1 . . . .. . i
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