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,WOPKERS'COMPENSATION DECI:ARj.JION. . APPLICATION FOR PLUMBING_ PERMIT
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1 hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 ,
insure;or a certificate of Workers' Compensation Insurance, 76A667A
ora certified copy thereof (fie 3800, Lab. C.) _,�t�,,,, COUNTY OFLOSANGELES DEPT. OF PUBLIC WORKS
Policy No/1,69 - �ny��� 'i'U.tt> .
Certified copy is hereby furnished.
❑ - FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING _
Certified copy is filed with the county building.i spec- ADDRESS SOll
;Ldepartmen. NUMBER FIXTURE OR ITEM ® FEE yy�� LOCALITY -
Data Applicant WATER CLOSET OV NEAREST
CERTIFION OF EXEMPT N F OM WORKERS' BATH TUB Q CROSS ST.
COMPENSATIO I RANCE - OWNER
(This section need not be completed-If the work Involved by SHOWER
the permit is for one hundred dollars ($100)or less.) LAVATORY 0 MAIL
I certify that In the performance of theworkfor which this ADDRESS U
permit is issued, I shall not employ any person in any manner - SINK CITY TEL. NO.
so as to become subject to the Workers'Compensation Lows. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS L L�
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITYL ,A TEL. NO.
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO, CLASS
LICENSED CONTRACTORS DECLARATIONDISTRICT NO. PROLE SE BY
I hereby affirm that I am licensed under provisions of Chapter 9 - GAS SYSTEM - OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER ��
and Professions Code;and my license is in full force and.effect. 5 PER SYSTEM I FINAL �••
,�jam� � � (J � DATE Z� 9i VALIDATION o
License Numberl+_l I I.Q�Lic. Class
r p FINAL 1 U
Contracto _ Date D d` BY 0
O.
❑ I am exempt under Sec. U
W
B.BP.C. for this reason 11'
Plan check fee � rn
Z
Date: -
' PLUMBING PERMIT ISSUING FEE$
.Signature
TOTAL FEE
Plan check applicant 5
SINGLE FAMILY ,.
HOME OWNER-BUILDER DECLARATION Name - ' - `�;'�'•�
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address 3307 '?;,•..}[f
Professions Code): - City Tel. No. 1 ITEMS
❑ I, as owner of the property, will do the work and the '
structure is not intended or offered for sale (Section TOTAL. 28 xx 150
7044, Business and Professions Code). D r
CONSTRUCTION LENDING AGENCY - CHECK 28.50
I hereby affirm that there is a construction lending agency for CHANGE •00
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name OO!)0-OOOl 10/20/89
Lender's Address 6311 1 AM 81 ICI
I certify that I hove read this application and state that the D
above information is correct. I agree to comply with all County
ordinances and State lows regulating Plumbing, and hereby
authorize repre
se motives
of t is County to enter upon the
ob - entioned property for spection purposes. (-•� ^
,�� ^`� SEE REVERSE FOR EXPLANATORY LANGUAGE.
5 na re of Permittee NI Date /� -