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� � WORKER$'GOMPENSATIONOECIARA(40N APPLICATIOfV FOR P�.UM�t�ta p�Rdl�IdT
I hereby affirm thaf I have a�ertificnre af consen�to self ,;qw;q
� insure,w a ceniflcata ot Worken'Compensa7ion Imvrance, CE B17(REV.10/81} -
or o certified copy ihereof(Sec.3800,i b.C.) COUNTY OF LOS ANGElES BUILDING AND SAFETY
PolityNo.�Cyb�� Compony �d� /�A. .,
� Certified copy is hereby furnished. , `q:�•I�f�.1
r-a � FOR APPLICANT TO flll IN(PRINT OR TYPEJ BUILDING B
I V1 Certified copy is filed witfi lhe county building inspec• ADDRE55 ot. B G� ✓
Yt� iion deparlmenl. � � NUM9ER FIXTUREORITEM � f{E LOCAL�TY ���/1'A�adXi.� �
� �9te I'�'�I�A',J APP�iSani�' WAiERUO�ET ` � NEAREST
CERTIFICATE OF EXEMPTION FROM WO 5' ,� BATH NB G� �� �. CROSS 5T.
1 COMPENSATION INSURANCE � SHvweR L/ �. OwnieR � •
� (Thif�Mion need not be eomple�ed if tha work�n�olved by G �`
t6e permk it fof ana 7wndred ddlan(5100)or less.) � LqVA70RY G 3Q .�,.. ADDRESS
I cerfify thpf in Ihn performance of Ihe work for which this
� permit is issued,I shaU not employ any person in any manner f SiNK �.► CRY hL �,,.3��
so as�o become zu6jett to�he Workers'Compa�tsation Lows.
� , - � DISHWASHER CONTRACTOR
��� Dote epplicant � ttOTHES WASHER ADDRFSS �►-1
` NOTICE TO APPLIG4NT: If, aker making ihis Carlifico�e of . � - � - �� -
' + Exemp/ion, you sheuid 6eromg-5vbjettYo fhe�Workers'�� � :� $WII,MM1tNGP00iRECEP7OR .
ji- "�mpensation provisions of 1he Labor Code,yoo mvsi forth- CITY f TFL.N0.93"�-��5�
I ■F` i.comply with such provisions or this perm�l shalf be �AWNSPRINKLERSYSTEM SYATE L�
� .emsdrevoked. WqTERHEATER L1tEN5FN0. �r {p ASS ��3�
, ._ ll(�NSED CONTRACTORS DECLARATION ^ _ !- _-----��DISTRKi-iaD...-----..-- ...� cROjtE55ED Bv ....
�_��ergb�aH�s.r�ket+aerlicertx�ur� io s-arti�a�a��--� -- --cASsvshFi--` ounEiS--L-- � G �
f (commencing with Section 7000)of Diviaion 3 of iF�e Business OUTLETS OVER . _ _ �
� and Rofeas�ons Code,and my license is in full force and effec#. r � 5 AER SYSTEM _ �� D�� ` '� VAttDAT10N' �
;� i;tense Number�7f��� iic.Class�_ �
� fINAL O
1z,� aY �
_� �r po1e . �
� 1 am exempt under ec. a
E . _ . . . _.. . __ . . . __ � ..- �. N
� 8.8P.C.7w fhis iedson . . .. - . � _ ,�...._�____W.�.�____ _...�.�---._�_�..-_--`- � Z�
�- Q�an-C�78Gk-�2E��-•�-�--�..._-'�______.._.�.�_._....4____..._
.. .... . _.�____.____�_ _
-f '- � � '� : ' . . . .. . - i . .
i - � � MUMBING PERMI7 ISSUING FEE S / 1�D � ,
1 Signaro � . . ._... ...._ . .... - e e..;_�. .� . �.
9
� _,. _ .._.. TOTAC.FEE� .. .._.. ''.. p
..... _... .._ .. :._... . .... ..._.. �-�
. . _.-_�_ ._., . -_,.. . .. . . . . .
• ,.__._ .,_�_:a .- :- � ... - 'I : �f� �
� . ..... _.._ _._ +
� ..... . _ .. . Plnn che[k opplicant ' -
StNGIE FAMILY
! HOME OWNER-BWLDER DECLARATION Name � - , ,_. _.
� i heraby affirm�ha1 I am exempf from the Cankactoi s ticense
taw for ihe following reason(Secrion 7031.5,8�siness and Address � �` i �
� ��siom Code): Ciry Tel.No.
LI,as owner of the propMy,will do ihe work ond the
otroctvre is nOt i�lended ot offe�ed fw wla(Section ,
7044,Business and Professions Code). �
CONSTRUCTION LENDING AGENCV
--. . . . _ . ... ..
I hereby affirm�hat there is a consV�cfion lending agency for , . _ � � �-� � � �� - � ��
. . .. .. .. - .
..th>perfoomance�of the wwk for which this pe�mie is issued � - -�� � �� � � � �
�Sec.3D97,Civ.C.). - .
Lendei s Name
Lender's Address �
I certify Ihot I hove read fhis opplitotion a�d stole tha�the �
obove information is correct.I agres to comply wi�h all Counry
ordinances and Srate lows regula�ing Plum6ing,and here6y
oulhori¢e representoiives oi fhis County lo enter upon fhe
� bove-memion �, prope y fo�pec�ion purposes.
SEE REVERSE FOR EXPIANATORY LANGUAGE
—/n�.�
ignmme of Permi tee � Date
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