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�2KS'COMPHNSAi]ONDECLARATION ' �sass�a
I hereby affirm that 7 have a certificate of consent to self cE en,z-ao; ��AP�LICATfON��F��R�.PL.0 M�B:I.NG PE,�RM IT
insure o a certifuate of Wurkers'Compensation Insurance,or , , � �� �,� � � . . ,�.
a cert�r�ea copy thereuf(Sec.3800,l.an.e.) COU.NTY OF LOS ANGELES BUI LDtNG AND SAFETY
��,«YNo.�'�c].o68k�,�any �ilum :lssoc.
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PR�NT OR TYPE) BUILDING �
Certified copy is fi(ed witN th c unty i ding in pection �.
fVUMeEFt FIXTURE OR ITEM • FEE ADDRESS 2 O Sunbri ht St,
�Iepar�y�t., ' LOCALITY D1 YI71GT1C�. B aI' �
Date��plicant ' n.V WATER CLOSET
NEqREST
eATH TUB CROSS ST.
1 CERTIFICATE OF EXEMYT[ON k�ROM WORKHR �
� COMPENSAT[ON INSURANCti SHOWER OWNER_ _ P�ja,]_ BOP(�.We]_1 ��
(This section need not be completed iF the work involved LAVATORY qooRess s�:me
by tt�e pe:mit is foc one hundxed dollars ($100)or less.) ' 'Y '
� . SINK c�rv D^��:mcnd Rr�r ��lb� ����
I certifY tha[in the performance oP the work for which this U
OISHWASHER
permi[is issued,I shal]no[employ any person in any manner CONTRACTOR �J'.hOIT�dS �roup .,�� �.
so us to become subject to the Workerx'Compensatinn Laws. CLOTHES WASHER AO�RESS 12900 GG � V(�, ���
Date Applicant 7 ��""
SWIMMING PDOL RECEPTOR .0
NOTICE TO APYLICANT:If,after muking this Ccrtificate of CITV G`G' 937-i667 TEL.NO. �� '
Exemptiun, you shuuld become subject to the Workers' �AWNSPRINKLE�RSYSTEM : ��'�� � ,
STATE C, LIC. '�
Compensation provisions of the La6or Code,you must forth- IICENSE NO. 35/Sj��� CLAS��'i ��
with�Comply with such provisinds or this permit shalt be WATEF HEATER
deemed revoked. DISTRICT NO. P OCESSE�BV
� _ GAS SYSTEM OUTLETS / _ ....
LICENSED CONIRAC7'ORS D�CLARATION OUTLETS OVER !� �
I hereby affirm tlixt I am licensed under provisiuns of Ch�pter 5 PE R SYSTEM �•-i A..ui.+t.�
9.(commencing with Sectiun 7000)of Division�3 of the Dusi- � PINAL k '
ness und Yrofessions Code,and my license is iu full force and ) P c DATE 3_'3 i—Cb`�, VALIDATION
� effect. � �
�,55542 SC�.�. �p�C 52222 FINA4 '�
License Numb Lic.Class p gy E
Contrac[orThOm`.S a'T'OU�Jfe ��Z�VZ ! ,
� � I am exemp[from the licensing requirements as t am d : P.lan check fee
]icensed architect or a registered professional engineer p�UMBiNG PERMIT ISSUING FEE$
acting in my prnfessional capacity (Section 7051, Bus-
� � iness and Yrofessions Cnde). , TOTAL FEE
l,ic,or Re�+.No. Date � Plan eheck applicant � .
1 .
E '
� . HOMH ON+NER-BUILDER DECLARATION .' Name ,
� [ hereby affirm that I am exempt from the Contractor's �� Address 1� `]'�,5� . ,
� _
License I.aw fVr Ine tollowing reason(Sectlon 7031.5,Rusi- ::'City Tel.No. ' �
ness and Pcofessions Code): . #• • o m e�5 � �
� I,as owner of the property,am oxclusively conVacting . . ' � a � ?, .Jr Q i -
with licensed cuntrnctors to construct the project � �
(Section 70a4,Susineas and Yrofessinns Code). . • v o � 2�5�� ,
t
CONST2llC7'lON LHNIJING AGI3NCY ' ' Q 3 n 2,,,g•� �
I hereby uffirm that there is a construction lending agency �
for the performance of the work for which this pennit is �
issued(Sec.3097,Civ.C.). � � f �
Lender's Name ' �
Finr,nce .:meric: i
Lender's Address � �
i
1 certiFy thut L have read tliis applica[ion and stx[e thnt the
t '
above informa[ion is correct.1 agree to romp1Y with all County . SPP REVI?KSS NOR EXPLANATORY LANGUAGI•; 6
ordinxnces and Stxte laws regulatinK 1'�umbing, �nd hereby �
author'i rep seRtatives of his County to enter -pon the � .
� abuve ntiu d roperty for inspection purpose. 11 � ��
��� � � U� , � .
` Signature of Permittee Uate �
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