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4 WORKERS'COMPENSATIONDECLARATION AppLICATION FOR PLUMBING PERMIT �
nnb��,nfLrm tMl I have n ranii¢o�e of�onsnM to self 76�B7A
,�e,cr n(er�ilico+e o(Wdkers'Cnmpe�sa'ion Insurnnce, CE B771REV.B/86)
� 1cam��ed copy thareof(Sec.3800,tab.C.J COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
P❑of�icy Na. Compony • �
Cer��fied copy is here6y furn:shed.
❑ FpR AOO�ICANT TO Flll IN(PRINT OR TYPE� �p�� /8 ST. �'✓� CT
Ce�nfiad copy is f�led with t��e county 6u�ld�ng inspec-
��o�depo��me��. NL'hABER FIXTURE OR ITEM � FFE �«p�ITY Dl�'���� ��J
Da�e Applitonl WATER ClOSET NEAREST / . �f 4 •
CERTIFICATE OF EkEMPTION FROM WORKERS' BnTN iU8 «C155 ST' 4��'� C�v
COMPfN5ATION INSURANCE Ownrt4 ��l' ��j���
(TAi�+�dlon nNd ne�M rnmplN�d if Ih�werk Involr�d br S+OwER �/�.p�
�ha p�rmH is for oe�hundnd de�lan(i100)or �.) lavqroar ��� ���� �� /(pU��
ADDRF55
I cen�(y�hot��rhe nerTo.mnnce o(the wo whkh th�s
permif is icsued,1 shnll noi emploY ony in any manner SiNK .� CITV D/��� TEI.NO.��.-
so os m become 5�6;et1�o�he Worke so��o ows. DISMw,sSNF.R �����
CONTRACipQ
Date Appliton CiO1HES WASNER
NOTICE 70 APMICANT� li, of r �ki� i Car Kale o A�� '
Exempnon, you should beco wbjeU o Ih Workers' SWiMMiNG POOL RECEPtOR , ,
Comuenwr�on wovistons of�he Labor Co e, mux�forth• ��T� � ' h���'
LAitiN 57ki1�.KLER SVSTEM
wi�h comply wi�h such provisions or � erm�i sFwll be STa7E uC.
c�eamed reroked. WATER HFATER ������ �5
LICENSED CONTRACTORS DKLARATION dSTR�CT Fk�. V�IQCFSSED B�
1 hereby offirm tMl l am I�censed under pior�sions ot Chcplr V Gn5 SVSiFM OUTlEiS ' \\
(comme�c�ng wi�h Sectlan 7000)o!�iv�sion 3 of the 8usiness p�i�FiSOvkc `������
ond Roiess�ons Ccde,ond my licerx is in fuli force ard eff«r. 5 vER�STfM ��/� � FINA � ��J VALIDATION 0
/�11 � DATE
Licanse Number l�c.C�ass ���r���s �� U
FINAL �
Convanw Daie BY O
U
� W
I om eaempi u�de�Sec. d
B.Bo.C.for ehis rsaun q
Plan check fee S 2
Dn�s: p�UMBING pERMIT ISSUING fEE S I O O
Signniure � .
TOTAL FEE I�O b ,
Plan check appliconi .
SINGLE FAMIIY
HOME OWNER�BUILDER DECLARATION Name , �
I hereby ofi�rr�tho�I om e.empt(rom rhe Co��rac�or's Ltcen�s q��esc '
Law ior tne iollowing reason(Section T031.5, Bus�nesa and . �
�essions Code): G�ty Tel.No. . . � �
I,as owner of the properry,will do ihe wo�4 ond�he , c. � ;;�b ri
s'ructure is not In�ended w offered for sale(Sec�ion
70e4,Business and Professio�s Code). „
CONSTRUCTION LENDING AGENCY
� " " � G;]�
I hereby offirm rhai rhere ie a conshuttion lending ogency ior
�he performonce of the work for whith�his permit it�u�ed • " • � ���T
(sec.3097.Crv.C.). •'"
��.i._—.,%
lender's Name
lender'c Addrees
I ce�t�fy�hot I I+ave read rh�s opplicarion and s�a�e rhof the ►
above in{ormo�ion�e tarect.I agree�o comply wirh all Couny
ordinance nd$�ote lows r ulo�ing Plumbing,and hweby
au!hori r esen�o ves �his Coun�y io enter upon the
� obov m ed tor in c�ion por0os .
q� � SEE REVERSE FOR EXPLANATORY LANGUAGE
\ �
`�aroture ot Ger ee Do�e /
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