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� ?VJORKERS��COMPENSATION DECCARATION��'� •''fu 'f b���:` � 7�'+t�� � �� � �
� r AP'FLF�AT��D1�����;PE�M��G PERMIT ; t
�l hereby�affirm that I have a certif<ate of consent io self �6q«,�q .. .. .. . . y+ -s y
`�insure,or a certificafe of Workers'Compensation Insqrance, CE 817(REV �0�81�o-. � a >r , � - 2 i„ ° .� �prvr-+
or a cerhRed mpy thereof(�c 3800,Lab.C.) ,...COUNTY OF LOS ANGELES BUILDINGlyIND SAFETY ? Y �"`'�`+'�° ;r . 4;
}� t � a� �4�`�.��"�'� � ,y
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}�.,,P�oliryNo. la ompony 'iG,Y��fh�.�'S.7 `�Y "� y 1 .. ;� . t,.
Certified copy is hereby fum shed. v ' ��� � �a �
/,,❑ `�t FORAPPLICANTTOFILLIN�PRINTORTYPE) BUIIDING + �•J a,{ ',l /�rs w T..��;�`
Ceriified copy s flled wilh the munty boilding mspeo . L_ ADDRE55 �T�,�L- � y����,�j�W iJ1 .
ho de ariment �l NUMBER FIX7lIRE OR ITEM C FEE � ���i
P�,�' (� LOCALITY �� �,x ti y� `�s
� �.7 �\S �V�YYu��\C.�fF' WATERCLOSET � L� � .. �"�'
.•�Date Applimni �s� NEAkEST
CER IFlCATE OF EXEMPTION FROM WORKERS' vY BATH TUB f� "� CROSS ST. °;��,�
COMPENSATION INSURANCE '� SHOWER OWNER ,� �� �� - � �
��C � �<t.{ � �
��.`(This section need noT be complefed if the work involved 6y i — MAIL � '�'�,�
-the permit is for one hundred dollars(S10tl)or less.) ', LAVAiORv � ADDRESS �r ' t S: �w. KQ �'� �
:�I ceriify that in the performance of the work far which ihis �`�r ���
SINK �t (� CITY T L NO. ,. �� -..�a,,,y�
,:permit is issued,I sh�ll no!employ any person in any manneY � 5ya �,,�C � C �J ���
��?so as to become subjeci to the Workers'Compensatian Laws' ,.} �� h"�`y �'�d�e�
UISHWASHER vv CONTRACTO �
. � — y+ 1'�G r
`�'Daie Applicant CLO7HES WASHER r � AODRC55�.y�y �^ �-5, `� F �r�� �
d 'i�, 4., �,0.�\�) � � �, �
:'P�nTICE TO APPLICANT: If, afler mak ng thls-Certifimte of M1.' :�
m tion, oo should become subect to the Workers SWIMMMGPOOLRECEPTOR (�
P Y I CI7Y ; 1 TEL NO. 'j�_ 1,�� �:
. .npensation provis ons of ihe Lobor Code,you must farth- LAWN SPRINKtER SYS7FPA �+r��C e' �� ' ���
,with comply w Ih such provisiors or ihis permit shall be � STATE � L�, LIC. r
�:deemed fevokrd WA�ER HiAiER ��y LICENSE NO. � � 1 CLA55 �'..��i � '
` LICENSED CONTRACTORS DECLARATION —�� -- --- oi5ieicr NO. r7 PeOCE55eo sr �' �
;.I hei'eby offirm thof I am licensed under provisians of Cfiopter 9 GAS SYSTEM OUTLETS � r�' �,+�, ,^ : i
� ;�' ;(commencing with Section 7000)of Drvisior,3 of ihe B�siness i OUTtFT50VER � .
�:ond Profossions Code,and my license is in full forw and effeU e 5 PER SYSTFM FlNAL / / ��Y
( /, / ,� ALIDATiON ' �
� � i�� [ 7� ,�-�1s._ �ATE I�/'7!f�'S i
�y.' 'License Num6er Lic.Class > �
k�p.'
� C��< C_ — FINAL ,.� ;
.�.Contracto�"�V �s�\i.'h�.�l�[�te � •, ` �~ BY �'�'`'�''�'� �!"'
'n' �, '.� ':
y ;.❑ I am exempt under Sec ,
� � �� �
B.&P.c.for rh�s�easo�,— $ plan check fee � ���,4'
`i,
� 3 � ��te� PLUMBING PERMIT ISSUING PEE 5 r(f S �. �"'
Signature ` +-'�
TOTAL FEE (J� ,jro . . i;Y'�- *�,z,%��� �;
Ty`�'• �?' Plan Check applimnt � u . � � "F:c� -'§-
�' SMGLE FAMILY 3 — � ��
'�`+l'�'�:5" HC7MEOWN€R-BUILCER DECLARA?ION q' Name , , . �`f��
" aeby affirm that I am exempt from�he Contraciors�icense � ' .
}t'",��:�; 'for fhe following reason(Sedion 7031.5,Bosiness and "� Address _ . ; u �.�-_�,
� Frofessions Code): : Clty Tel.No. �.'-�
���
I,as owner of the property,will do ihe work and Ihe �� � �` � Y �
ti`cS�� siructure Is not niended or offered for sale(Section . , �e"1;�.� #��
,p,,,;y 7044,Bos�ness and Professions Code). � (�t`,�+y�
��-'p'� CONSTRUCTION LENDING AGENCY �,F °k;'
��°�I hereby affirm Ihat ihere is a mnsiruction lending agency for {;,
a.i�.-�a�the performance of the work for which this permit is issued ��,:
.,�,�vi,`�(Sec 3097,Giv.C.). :� �µ
r£
ts ��
r �;�Lender's Name ���:�. ��
qe "F '�
'�`!Lender's Address � ',�""��'� �
� ,'�I certify that I hove read this application and sto�e 1ha7 ihe � �
�.;above intormation is corred.I oyree ro comply with oll CouNy '� � �`��
•:5 ordinances and Stote laws regulating Plum6ing,and here6y ��.',. n� ,
� �outhorize representntives of this County to enter upon the ., ��,�, �
�ab e-mentioned pr perty for inspeUion purposes.
t : �i�� � � SEE REVERSE FOR EXPLANATORY IANGUAGE � ,
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