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'"°RKE"S"�"^�"�„'°"°E�`R""°" APPLICATION FOR PLUMBING PERMIT � �
I hereby affirm tha�1 hove a certifico�e of wnsem to aeii �bq�q
'nsure,or o CTrtifi[pte oi WakeR CompBnsafion InaVrUnce, CE BU�REV.1o/BI) - �
Oo ce.+�fi o rnaroof ec.3600,lab.c.) COUIVTY OF LOS ANGELES BUILDING AND SAFE7Y
,�N�`�ldlBt�m�YY Ylt,t'fuA�L
Cmfified copy ia hproby fv�nished. ,
❑ FOR APPLKANT TO fiLL IN(PRINT OR TVPE) BUILD�NG . �
CEr�ified copy is filed Wifh ihe county buildim�inspeC- ADDRESS / -�
tion deporlmen�. NUMeER FURURE OR ITFJYI Q FtE
7 S -K.S w�"°n' �I'J N A
ppte�L� Appli�Cnl . WATER C105Ei PJFqREST
CERTIFICAiE OF E%EMP710N FROM WORKERS' �TH�B ��' .
CqMPENSliT10N INSURANCE S�R pwN¢q �� . '
(This�ecflon nNd nM 1»rnmplatad 1i ih�work tnvoWed 6y ?
tho p�rml�U�re�'on�h�ndnd doilan(5100)or�ns.) �,qyq�y �tt
AOORE55
I eenify�hot in tha performance of the work fpr which this , �
permit is issued,I sholl no�employ ony penon in rnry monner SINK C17Y � 1E1.NO. �
so as�o become aubject ro�he Worke�Compemafion Lawa. �W�Q �
CONTRACTOR G ,.� -
Oate Applimn� C,IpTMES WASMEa �
NOTICE TO APPLICANT: I{, after moking rhis Certificata of. �R� " � � .
Ena'mplion, ynu should bemma subjecr ro the Workeri ����'������
Compemotion provisions af�he laba Code,�you mua�foNh. C�� � �.� ��
with compty wirh such prorisiom or this permi�shali be �����RSVS7EM
SfAiE IIC. a ;
deemed revoked. yyp��qyEp uCENSE N0. C1a55�" ' :
LI(�NSED CONTRACTORS OECUIRATIQN o�src�n wo Br �
I hpre6y affirm tFw�I am licensed urder provisiom af thopter 9 G/3 SVSTF/N OUTLETS �� � i
(commenting wifh Sec�ion 7000)ai Division 3 of Iha Busimss pUTIkTSOVER , ��. !
aMl Professions Code,and my license is in full fwce ond effect. 5 PEA SY5fEM FINf(L ! � VA IDATION 0 `
b� DATE o ,
Litenee Nom6er Lia Goas V '
FINAI � '
Conhotlor Date BY � 1
W �
❑ I am e.empl�nder Set. . �
8.8P.C.fw this reason � :
Plan check fee � ? �
��� MUMBING PERMIi ISSUING FEE S `Q T�
Signalure
TmA�,� 3d
Man check apPkwnl . i
SINGIf FAMILY
� HOME OWNER-BUILDER DECLARATION Name � _ . f`� ?J rJ.�A
I hmeby affirm that I am exempl from fhe Controdor"s Lice'ne � � ' �
low for the foliowina reoson(Seclion 7031.5.Bus�ness and A�� . . i+• • • • ��J `
Rofessione Code): City Tal.No. � •��3 Q 5 0
❑ I,as owner o4 the propeny,will do�he work and tha '
strucMe is not intended or offered fw sale (Sec�ion � ► . "� • •J Q 5 C i�
7044,Busineas and Rofassiom Code). '
CONSTRUCTION IENDING AGENCY . � 0�,��5��S .
I hereby affirm rhet there is o conshutlion le�ing agenry fw
I �he perfomtence of tha work for which ihis parmit is iswed ._.. .
i (Sec.3097,Civ.C.). , � .
Lender's Name
lender i Addrass i
I cer�ify�Frot I hare read this opplicarion ond sto�e iho�rha ► . �
abave informoYon is caret�.I pgree to comply with all Counly
ordinontea oM1 SMIe Ipws requloting Plum6ing,and hereby �
outhoriza rev�ele�+o��was of�his CouMy to enrer upon rhe '
abor entioned roperly or in pec�ion pu�poses. �
` � / SEE REVERSE FOR EXPIANATORY LqNGUAGE �
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