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•WORKERS tOMPENSATION'DECL�ARATION ✓ � 5 g� 6 y �
� �„yi,�.i,.�=ARPC�ATI�N�FOR PLI�M�II�G�PERM'IT ��1� t °� ,�
I�hereb�affirm that.I have o certificate of consent3to se1P�Am 76P;6�Tq'�'ai'° M �'°�.aNri � . r�i � � . , q��
,k; ."� : ,� � 3����'�> �r��e� � h�,
jinsure,or n certificate of Workers'Compensa�ion Insurance�,��ce sn(aev l0iely� , � i �,i � ,tt � � . � �i . , . �,,� { +row�, ,_
for a certified copy thereof(Sec.3800,Lab.C.� �'�� �'�''��s COUNTY:OF LOS��ANGELES ti',. BUILDING AND.SAFETY ��'"'`i M �''�^ � -"
d "t':t,� .� ��Y, '�! . ,�� �
,Ocy"No.NOSO�SZH�ompony F3YIR0L'S � �: FS�`. � �'r ��„,"�$-� �'.
� �a:7' .,�.• Lot.38�a_ ,F�.,,„.�
-.Cert fied copy is hereby furnished.
;❑ �, '�,; FORAPPLICANiTOFILLIN�PRINTORiVPE) qDDRE55 1439 S. Stonecrest P1ace � �.�
:Cerllfied topy is filed wiFh ihe[ounty building nspec {r� :� NUMBER FIXTUREOR ITEM (a� FEE . d�
y .. twn department. � � jr�; �ocauTY k
£ � �}a WATER CIOSET � Diamp.nd $ar �, ��
� .iDate Z�2./RS Applicani P-R_(1_ P7nmh�no�� ; � NEAREST � ^��
� � J, r� .._'1 CROSSST. ��� �:�,
� CERTIFICATE OF EXEMPTION fROM WORKERS u� BATH TIJe �/y g
: COMPENSATION INSURANCE ��€ �: SHOWER `� �� OWNER Bramalea Limited ' ����'
� :(This section need not be aompleted if the work involved by��d; MAu � �:
`"Ifhe permit is,for one h�adred�dollars(5700)or less) �,� ; tqVATORr /A� nooRESS 3151 Airwa AV'2. STE N -.�.
�'1 certify thal in the performance of the work tor which this���„;, SINK f/!7 �-CIN TEL.NO. �
�;permit is issued,1 shall noi emplay any.pereon in any manner� � QOSCB MOSd ,�� SSO—ZOOZ "�•
° k+;;so as to become subject to ihe Workers'Compensa�on laws :� � `,,� � �
DISHWASHER y�[� CONTRACTOR �t�
� ��,�; � � P.R.O. Plnmbing
� Applicani ' 4; � CLOTHES WASHER � ��
�.soare � ADDRESS 4418 E. Cha an `�
5,. '1TICE TO APPLICAN7: If, ofter making ihis Certificate oF � � ,�
� �ion, ou should become sub'ea +o �he workers SWIMMINGPOOLRECEPTOR i �
P v i �� an Orange ,�i.No. 630-8441 , �'
?� ,.,.,�ensation o�isions of the Labor Code, ou m st forth � t
P P� Y , a LAWNSPRINKLERSVSTEM ;��
r� ifh comply with such provisions or ihis permit shall bedk�' �� Siaie uC. ����`
s � deemad revoked.: , < �' WATER HEATER /_ �' ucervse rvo. 443774 CLA55 Ci-3E1 .� ,���
�:�.
i u �,� LICENSED CONTRACTORS DECLARA7101+� �" '+' v� DIST21C7 NO. FROCESSED BY
�y v1� I hereby affirm ihat I am licensed under provisions of Chapter 9�*.•*5°� GAS SYS7EM OUTLETS � v y
' commencin with Section 70Q0 of Divis"on 3 of ihe Bos ness����
4 ( g ) { �`yy� OUIlETSOVER �+': �
1 r a and Professions Code,and my license is in full force and effecf'"�� � 5 PER SYSTEM FwA� VALIDATION t �"'�ti
I� �
t '.,License'Number 443774 Lia Class �(,'—��_,'4tt� DATE �.7'�d���" �f� ��
t '. - �$ FINAL j Y� �'�
I�'` �� Comractor P-Rfl_P7ivnbin�Date 7/9/RS �� BY �te.t/� � ��,��.,
(`��' ;k"� � c��e„'�g°
,� ° i am exempt under Sec � � �pk.'
l� ; B.&P.C.for ihis reason �,{� � ��
i r;; � Plan check fee � � � �
` Date:_ � �
I � " �;;�'� PLUMBING PERMIT ISSUING FEE$ �E� ;;
l s ' Signdt�re � ric�,.� � °� �;
� �' �i TOTAL FEE � �
j ��t ":�,�3 _
� ��,� . ;���Plan check applimnt c i L���1
1 .��,� SINGLE FAMILY �"y��� .�.fl � � f p�� � :
� „� � HOME OWNER-BUILDER DECLARATION �,�� f Name . v ,
� �:=by affirm ihat I am exempt from ihe Controdor s licensep,:9 , � 2 1 ���u r,� �. 7�
� � ,' • for ihe following reason(Section 7031.5, B�siness ande aoress 0 - -
,� Professions Code): ;�p� Ci1y Tei.No. � � (,{)J(�i 1
F n ..
L_J I,as owner of ihe property,will do the work and ihe ,�'�'� Q 7.j r—�Qi J � ,� '�'
siructure is not intended ar offered for sale (Sect on �+�s �3 :
7044,Business nnd Profassions Code). L""�... ► � ?'
tl�
; CONSTRUCTdON LENDING AGENCY �y,p� � �Y i "-
x; I hereby affirm ihat�here is a constr�ction lending agency for '�@, � f�
�� 1he performance of fhe work for which this pe�mit s ssued �
�, (Sec.3097,Civ.C.).' . �;��;�� �.l
� � ���a
z : Lender's Name "� �
�9. Lender's Address �'�"�
�:
` I ceriify ihpt I have read fhis application and state ihat ihe�� ► "}� ;
�"�above intormotion is mrrect.I agree to comply wiih all Cou ty�"�; g
! ordinances and State laws regulating Pl�mbing,and hereby�cf�y �
� .i authorize representatives of this County to'enier upon ihe�w�Ft ' '�
� q6 -mentioned toperiy for insgetlion pur oses. �° ��'v �
�"' SEE REVERSE FOR EXPLANATORY LANGUAGE . . i
� ��:�
� ri , . , � s
f � Signature of Permiflee ate �`" ' � t
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