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1522A
_ WORKr:RS��aMpLNSAT��N�r:c�AaAT��x '8A66JA qpPLICATION FOR PLUMBIIVG. PERMIT [ heroby affinn that L 1�ave a enrtificate of consent to seif ce en�z-eo� . inaure,or s cert�ficate o(Workers'Compensation Insurance,or � � . � �certified copy thereof(Sec.3800,L;ib.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY � PolicY No. �•'�C1`���.mPan➢ �2n:m:�t':i. . . � ('crtified c�py is herehy'1'urnisiie<I. ' FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING \ ..� \ ( � � Certified co . � NUMBER FIXTURE OR ITEM • FEE '�'DORESS ���.p�•� �...C.��� �'�RC�`�i�:�'C �:', py is ti]ed with the county building in,spection �lep'r mect. � LOCALITY D�te- qpplii:en[ �--j���-+�+rt �� WATER CLOSET NEqREST � \,'�rnt��1K C'C' �- Lt: ^ � BATH TU8 CROSS ST. � � CERTIi�ICATE OF EaEbiPTION FROM R'ORKF;RS' �- ��- �- �` COMPENSA"IIUN INSURANCE SHOWER OWNER ��y,��, . �.r . LAVATORY MAIL ` t ,}. (TLis section need nu[ be cumpleted if the work invohed ,4oDReSs � `�t:':��,y ��.�,e�r1,�Nc� �� by the permit is for one hundred dollars (SI00)o� less.) SINK ' � � CITV j � TEL.ND.t� CJ i"-�c•_.,`-',�_' .)�1�•' I certify ffiat in thz performance nf the wnrk for which this DISHWASHER � CONTRACTOR C' � x permit i�issued,I shall not employ any person in any manner _ �,��,�,�� �5�� �„c�s �'O so as to hecome sabject to!he Workers'ComVensation Laws. CLOTHES WASHER ADOAESS i'��� � ��G"� � '�� �C�.1 `.=:��:� !y� Dn[e_ Applic.mt_ � SWIMMING POOL RECEPTOR NG7ICli TG AFPLICAN7:if,aiter makin this Certificate of CITY � TEL NO.( t�..,`^ � � s ..YC'v.;l�... �1 1� � Exemption, yuu should become sub.iect to the Workers' LAWN SPRINKLER SYSTEM STATE ^� LIC. � ComU�nsation prorisions r,f the C.abnr Cnde,you must furth- LICFNSE NO. �s'.��y")�� CLASS����` �`��� wiih Com 1� with su�}� WATER HEATER p) provisions o� this permit shall be � I dcemed revoked. :-1'� DISTRICT NO. PROCESSED BY GAS SYSTEM OUTLETS L[CENSL:D CONTAACTORS UF.CI,AItAT10N OUTLETS OVER j���7 �ni f hereby affirm that I am licensed under provisions of Chap[r,r 5 P�R SVSTEM --' - ��� � i�_ � 9 (commencing with Seciion 7000)of Divisiun 3 of the Busi- 1 ; FINAL neas anJ Yrufessions Code,and my licencn Is in full force ancl ''���.E�.,% t✓ -���.`.°�L� � Cl<-� DA7E �_.�—��- VALIDATION cffect. Liccnsc Yumber.�'J�17 l,)�Lic.Class �����='��'—1 T'; BV A [ , 1' ` ____. � Contractor`-•s.\.J� ��Date ��-�'T 1��..... � � 1 am exempt from the licensing raquirements as[am a " Plan check fee licensed xrchitect or a registered professiona] engineer ?LUMBING PERMIT ISSUING FEE$ ���"'"') ucting in my professional capacity (Section 7051, Uus- �� i• . iness and i'rofeasions Code). TOTAL FEE v �. ri�t7 Lic,ur Re�.No. Date plan check applican< ��, �, � � HOti1J�.UWNF:R-3U1!,UEKllt�CLARATIO�? V Nar*�e C�.... . .— ... . C' z .. Address l'�'�l:��p �" 1� . ] hereby affirm that C am exempt fcom the Contractor's �.L\��] .,���.�� License La�v for[hc fotluwinK reason (Section 7031.5,Busi- . City ,1r;�•� Tel.No. r �'t' � `1'" ness and Professions Code): .., ' � 1' "�"F�'}` �� �G.i'p I,as owner of the property,�m exclusivel con:ractin � � ��"`"�' ����� ❑ Y � �(�jrC'y'�.C�L%rrZtFC/= [-rY(56r�-(�`i' :-/�I�.f �k� o . , :5 witli licen4ed �un[ractors t�� construci the project • (Section 7044,BUsinessand ProPessions ibde). �' � ° ° ' 2 JC O ,�� CONSTRUC7'ION Lh:NUING AG�NCY � m �1� � I here6y xffirm thut there is x constmction]ending agency . '" ° � 2•5 U` fnr [hr. performance of the�vork for wliich this Permit is ... idsued(Sec.3097,Civ.C-). �, G��U�i"8 L Lender'sName � >�^..•�- ��,��S:.C\ LendePs Address � I certify thut 1 have reud this application and state that the � ' abuve informntion is currect.I egree to comply with all County g�.;�r,lt�;VN:RSL tOR EXVLANATORY I,ANGUACF ordinance5 and State laws regulating I'lumbing, and hereby authorizc reP�esentativcs of this County to enter upon the above-mentioned property fur inspection purposes. ' Z� �� h _ •�..�a3v�•.�..ka..,,.,x. J..��t `�,�. Signature of Permittee llnte G -o S � �'O Z ;� N'G �`sN'N C � D �Z y' � ��� �,m �`? � v NUC r '.� tT''�Z pt'i Z`-� �'fN' O � CafiN' '. i � 'C1 �NI�.G) ���,'1'G�'G I� < v� ''i z'!, X.r�n 1 W!`L' c�n , vY � -��` pr. 4', C i?'{ I 2;p�' O I '" �,�',9 ���xl 1 ' � . 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