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WORKEkS'COMPENSATION DECLARAYlON � �eweetA �
--- �: -APf��lGAT10N FOR PLUMBENG' PERMIT
' 1 hereby�afficm-t6af-I�have�a`certificate�of consept�to self � �' ce�n{eao � ���� ������
insure,or a certificatepf Wotkers'Compensation lusurance,or . i
' a certified copy thereoC(Sec.380� Lab- )
COUNTY OF LOS ANGELES BUILDING ANDSAFETY
Policy No. Compan �
� � Cectifie3 copy is he�eby fu[niShEd. . FOR APPLICANT TO FfLL IN(PRINT OR TYPE) AUILOING - �n� '�
� IX I CertlPied cogp is filed with th unty.bp�lding inSpeMion NUM6ER FIXTURE OR ITEM ��� F�� NEAREST • � il�
L� ..
..�. ........ .. . ....... .. _ .. ..
� H� �I Qaj�m_e jt.� . ... . . LOCALITY .!1_
' .. INATEA CLOSET-.. -_- 4IXSl/�.. -.___. -
Date�;��::lL�T.lYL App(ican . . .... .. . . . . _ .i
, �r BATHTUB CROSSST.P .
CERTIFICATE OF EXEMPTION ROM WORKER$' � � � _ .. _ " _ _ _. . �
. COMPENSATtON1NSURANCE � SHOWER OWNER- �
LAYAT�QRY . . .. MAIL.. ., . ,. _ 1
(This section need not be completed if lhe uKlck it{vU(ved ADDRESS ..�,�Z. n�,� �
by the pecmit is fo� one hundreJ_�oAua fSlOQ)_oc.less.�.__ SwK __ __ - _ } s
� CITV TEL.NO. 0-
[certify that in the performance of the work for wfiich this - ���'�'� ��' � V �
DISHWASHER
permiF is issued,I shall nof employ any person in aay manner CONTRACTOR
so as to b co e svbject to the rker ensation Laws. �
CLOTHES WASHER ADORESS Q
Dat � l Applicant SWIMMING POOI RECEPTOR ' �
NOTICE TO APPLlCAN7:If,afte aking this Cer[ificate nt� GTY'^ � TEL.N0. �2 W �
Exemption, you shoulA 6ecome subject to the Workers' LAWNSPRINKLERSYSTEM p.
STATE /� F� �
Compensation provisions of the Lxbor Code,you must forth- � LICENSE n70. bL X C ASS 2
with comply .wi[h such yrovisions or Fhls permit shall be WATER HEATER �
deemed revoked. - - , GAS 5YSTEM OUTLETS DISTRICT NO. PROC SSED BY
LiCENSED CONTRACTORS Db'CLARATION OUFLETS OV ER %O �41
i hereby affirm that i nm licensed undec provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)�f Qirision 3 of the Busi- FiNA� �����
ness and i'rofessions Code,and m license is in fult force and DATE VALIDATION �
effect. �
�� FINAL`s��f,� t�Frz
License Number Lic.C(ass. BY �r <<��y
Contrackor Date �J � �
� I am ezempt f m the.licensing reyuirements as I am a Plan eheck fee �
licensed architect or a registered professiona) engineer pLUM81NG PERMIT ISSUING FEE$ �
acting in my prnfessionnl capacity (Section 7051, Eus- �
iness and Nrofessions Code). � TOTAL FEE t� �
L1c.or Reg.No. Date Plan check appiecant � �Q��
HOb3E ON'NElt-BU7LUER DECLARATION Name � - �
V �
i
I here6y affirm that [ am exempt from the L`ontractor's Addreea �
License [aw for the tbllowing.reason(Sectioa 7031.5,Busi- C�tV Tei.No. �
- nesa anJ Professions Code): /rj. �a 4-}J
. � I,us.owner oi the property,am exclusively contracting �
r with� licensed contractors to construct the project /��/,'p� �
�F. (Section 7044,Business and Yrofeasrc�ns Code). - . �
� � � CONSTRUCTION LHNDING AGENCY . �
• I hereby affirm ihat there is a construction tending agency
tor the performance of the work for which this permit is
issued(Sec.3097,Civ.C.)- �
Lender's Name . . �
Lender's Address
I certify that E have read this applicution and state that the �
above information is coerect.I agroe to eomply w3th atl County SEE REVERSE FOR EXPLANATDRY LANGUAGE -
ordinances end State laws regulating Piumbing, aod hereby �
authorize representa�ives of this County to enter upon the �
above- enti ned///p�ff o rty for inspection purposes. � �
_�,� �OS/�f�� . �
Sg'nature errt�ttee Date . . � �\I
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