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�RKERS•�oM��ATioN oE�w�T�oN APPLICATION FOR PLUMBING PERMIT � �
I hereby offirm Ihar I huve o cm�i4icate of conxN ro uli 7yqyy�q i
insure,or Q cerr+fiwte of Wwken'Compensation Ihsurance, CE 817(REV•10i81J - - �
or a certified copy ihereoi{Sec.se00,Lab.C.� COUNTY OP LOS ANGELES BUILDING AND SAFETY !
P�allcy No._�_Company � � ;
Certified copy is Ae[e6y fomished. BU��NG
QPOR APPIICANi TO FIIL IN(GRINT OR iVPE) A�� .� � . i
CeAified copy is filed wi the county building impeo
tion dCpurtment. NUMBER FIXTURE OR I1FM � FEE ��ytlN r i
! /• ' �
Oaro Appliycm 1IYniER GASFf . �ST �, .. s
CERTIFICAIE OF EXEMP�ION FROM WOR RS' BAiH TVB ��' � t
� COMP�NSATION INSURANC� S��R pyyr�p .,�
(This s�eflon rfiad not bs camplefeE�f th�work(nvolwd by �
the permt►ta for an�hvndr�d do0an(5100)er lers.j �pyp�pgy p�p� - � � '
I cenify�hat in the performance of the wo/k fw which thie - �
I permit ie is�oed,1 sho6 no�emptoy arry qersan in oiryr manner �NK . CIiV �L w0. �
'�o m b becmne wbjecf ro the Wprke�s'Com o LavR DISHWASHER ��,q� r� � t
�� `�G� aR ��'�� e �t � �
A �{�pM� I ClOTHES WASHER A���
NOTICE TO APPtICAM: If, oher meking th�a Certifhate of � ��c� � ✓�
Ex tion. SWIMNUNG POO�R�ROR �
emp .yo� thould besome eub'ett ro �he iNorkars', � crtr � �.np
Compenwrion provisiom of fhg Labn�ede,yo�musr fa.tb- � ' � � .
mu IqWN$pRINKIER SYSTEM .
with tomply with such prowisiom a this permit shall be STAiE r� UC. � ;
deemed rovoked. . WATER HEATER LICE!!SE NO.J . GIAss �'3
. IICENSEU CONTRACiORS�7ECLARATION oiSrRic7 np. sr �
I AelebY offirm tFw�I am Ktemed�ndBr ProvisiP�f OF Ch�P��9 GAS SVSTEM OUTIETS - �Q
(commenci�g wi�b Section 7p00)of(Nvision 3 ot rha B�sirress .pUrypts k �' i
! ard Vrofessiqtu Goda,and my licame is in full fqrce emd effect 5 PEN 5 �J O oA� ? I ��{/Li V LIDATION � '
pQ �.� -�� ZL�
� License Num6er31• e.CYasa3�^ � � ;
� (
controc�w��`_____� "�r BV � �� !��4��C.`�L% V 1
w !
�� ❑ �om exdmp er Sec. � �y ;
6.8D.C.fw�hiz.eas � � z I
Plo�check fea
fe:
- PIUMBING PERMIT tS5U1NG FEE S /� Q r
.Sigrature .
. - T07A/FEE rp O �� O B.g A � '
I
.. . Plan check oppiitant . . �• • • •�5
SINGLE PAMILY � j
HOME OWNER•BUIIDER OECIARATION Noma � . - � • •� 6,5� j
I hereby aNi.m rhar I am axempt fiom the Conhocror's License � �
low for the following reason(Section 7031.5,Business and �`Q65 ' � • • •� 6.5 Q c2.> >
Professions Code): City Tel.No. � ' �
❑ I,os owrror of rhe pope.ry,wi�l do the wak and the ��,1 9—8 4 �
. tlruduro is nof in�ended w offered for sale(Seclion � ' �
7044,Business and Vrofeasions Code). . �
CONSTRUCTION IfNDING AGENCY . - . � . . - ,
� I hereby affirm that there is a conskuction lending ogenry fnr .�
� the performonce of fhe work for which this permil ie issued ` . . ' "
�� (Sec.3097,C(v.C.�. �
l
i lridm i Name . '., . �
ILender i Adehess � � . ,
I ce.tify thet I hove read this opplico�ion ond aM�e�Mt the � � � '
above infwmaHon is cwrect.I agree�o comply with all Couny '
�� ordioonces aMl Slate Inws reguloting Clumbing,and heroby ,
�i aothoriza representatives of rbis Coun�y to eNer upon the - � .
� above- - rnioned properry iw inspxrion pu�poses. �
� � SEE REVERSE fOR EXPLANATORY LANGUAGE
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