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WORKER3 COMPENSATIONfDECLARA7,GON ,:. � - �: qpp���CAT�ON���FOR���P�LUMBINGwP�RMIT ��� �
1-�hereby affirm ihat I have a cernficate of mnsenh to selfL°� �bq��q:,,� 4 �.,c, • �j.� QOUI2� .�A� T11COE`�'1 ��`
'insure,or r�,cert f'cdte of Workers'Compensation Insurance v�F�..,CE ei7(REV t0/8�) . �; . y �, � � � � '+�
�or cy ceFti9iedcopy�hereof(Sec.3800,Lob.C.) .��rr;' � ��= COUNTY�OF LOS�;ANGEIES BUILDING APID,SAFETY � �t�µs } ,.
•"?r
WC Selecb Ias � . . 3�
�.�P❑olicy No__'����ompany . � q � .,� , ,� ;
Cerhfie m areby furnished ��s'� ��"�'`�''�' ' � ;�
FOR APPLICANT TO FlLt IN(PRINT OR TYPE) BUILDING 641 Stron bow
`'O Cerhfied wpy is filed wdh Ihe coun uildmg inspec -��`- ADDRE55 �
fion depariment. (}QQ BZ' $ ��b$• �G '� NUMBER FIXTURE OR ITEM �r FEE ,
6-22-$5 �:. �ocnurv Diamond $ar
�.Dqte Appliconl .� WATERCIOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' ��
�`'� BATH TUB ceoss sr. Sunset & Strongbow
COMPENSATION INSURANCE 'G' SHOWER OWNER K�� Raval
� ,,(This section naed�ot be wmplefed if fhe work involved by � < MA��
,'the permiT is for one hundred dollars(S�00)or less.) LAVAiORY ADDRESS 641 S�ro bOW
��d certif.y ihni.in ihe performonce of ihe work for which this '
i;permit is issued,I shali not employ any porson in any manner " SINK dTV TEL NO. C�
t �jso as to become subject to the Workers'Compensa�ion Laws. �" Ond �Sx '�Jg �g�73 ��
� : � DISHWASHEH CONTRACTOR ��
� ; Geo Brazi,l Flbg. & Htg.
?�Date Applicqni CLOTHES WASHER
ADDRE55
�.;NOTICE TO APPLICANT: If, after making this Certifiwte of � � ].'�f�4�O SO �2'09.C�W3,'y
;�;�Exemption, yoo should become su6ject to the Workers' � d, SWIMMINGPOOLRECEPTOR 1�p ��
f-�Com ensation ovisions of ihe Labor Code, ou must forth- ��T� (73T(�lSSE� ���G`fc.7 TEL.N��..S2
� AwithP[omply w�ih such provisions or this ermif Shdll 6e . � �AWN�PR�NKiFRSv�TFM �� ,
, a sTnTe 4�4167� `�� C 3b
' ���.deemed revoked. ����; 1 WA7ER HEATER{,',}lAT1�E OU �ICENSE NO. CLA55
LICENSE�CONTRACiORS DECLARATION �'� DISTRICT NO. PROCESSEO BY �
3 �} - - ' 'r� GAS SYSTEM OUTLETS ;�
� �,:.I hereby affirm ihai I am licensed under provisions of Chapter 9 � � �Q �, �
j '(commencing wifh$eciion 7000)of Division 3 of the Business �b'. OUTLET50VER
�'�and Professions Code,and my hcense is in full force and e�fect. ` 5 PER SYSTEM " , '�°`°�'
FiNAi V IDATION �
�t DATE " ` ��'
.w.License Number� ��678 lic.Class C' 3� � 6!'":
AC �
��Contractor Piumbin� Date��2����✓ * g'r A�i' S �.�
�-�..;`
� T'�+❑ i om exempt under Sec. ��a
� !<. � �,?:
B.&P.C.for this reason
� — �; Plan check fee � '
Dofe: �'z
�" PIUMBING PERMIT ISSUING FEE$ ].O 5�
� Signafure Pr: , �C 5� .
r�
� TOTAL FEE ��
� ', Plon chack applicart � ��y� a
, SINGLE FAMILY .� �p P":�� ?.
' HOME OWNER BUILDER 9ECLARATION �� Name � '.
"�"I hereby affvm ihat I om ezempt from the CoMractor's L�cense � ' +i
� �i..,.,p�,u,e t�n�.._..y. ___ Address �
� .,Professions Code): �V� "V"'Vy'J� V�� ���V�u j .. . G t'�, .�:;
;":❑ „ ,._.. : _ ,._�no,� o. . " '_� :V Ciry Tel.No. ,.. � '
I,as ownar of the property, 'll do fhe work and the � � °.I,j ��'
structure is not Intended or offered for sale (Section ► f r c;,::
7044;Business and Professions Cade).
0�
CONSTRUCTION LENDING AGENCY
i I he�eby affirm that�here is a construcfion lending agency for � '
.�;��'the performance of ihe wark for which this permit is issued ' � .
;:%.(Sac.3097,Civ.C.). �
,�:
,�,Lender's Name
'��ir'�Lender's Address
;`�I certify Iha�I have read Ihis applimtion ond stote ihot ihe ►
,� "�above mformation is mrrecf.i agree to mmply with all Counfy �
:���ordinonces and State laws regulating Plumbing,and here6y , ,
',authorize represeNaiives of this CouNy to enfer upon ihe �
5 ,'����abov -mentioned properiy for inspection purposes. � � '
j3�k�'� � �� ry�j SEE REVERSE FOR EXPLANATORY LANGUAGE .
I�k1�. L� P "Z Z'r i�
j � Signoture of Permiftee Da�e
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