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'WORKERa'COMPENSATION DECLARATION APPLICATION
PPLIC A� ION FOR PLUMBING
p UMBI p$,�s PERMIT
I hereby, affirm that I have dertificate of consent to self in- 40.0026 DPW 4/90 P'ir LL /"� Y ICI IL'LY�H9 0CI'LY PERMIT
sure, or a certificate of Workers'Compensation Insurance,or a 76A�7A C, I
certified copy thereof Sec. 3800, lab' C.) IUI
Policy No. c�/� Company/yyy LLh� 1[./INid. . COUNTY OF LOS ANGELES DEPT:OF PUBLIC.WORKS
❑, Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE)
Certified copy is filed with the co building spection ADDRESS
LOCALITY 7Q/ eIif/1/ (/G
d/;/prt nt. NUMBER FIXTURE OR ITEM (d FEE LOCALITY ��✓IG / !�
WATER CLOSET(TOILET)
Ze�APPlican - 'NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' ;//q\/\ -' 1J BATH TUB - / CRO55 ST.
COMPENSATION INSURANCE SHOWER 3a 90 OWNER �GY� , •E
(This section need not be completed if the work involved by MAIL /k A //
the permit is for one hundred dollars ($100)or less.) LAVATORY a Q. ADDRESS g c. LAJC/'7
I certify that in the performance of the work for which this per-
mit is issued, I sholl not employ any person in any manner so SINK
K� 3� CITU TEL. NO.
as to become subject to the Workers' Compensation Laws. l DISHWASHERt -in�/� �"C CGC�IIB//t
Date Applicant / CLOTHES WASHER VOLr ��
41
NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS
em tion,you should become subject to the Workers'Com en- SWIMMING POOL RECEPTOR
P Y I P CITY kaLq
?4m
lyt TEL. NO.
with
provisions of the labor Code, you must forthwith comp- IAWN SPRINKLER SYSTEMS �r
ly with such provisions or this permit shall be deemed revok- STATE /� J UC. J/
ed. / WATER HEATER / LICENSE NO. oc�/ CLASS/J� V-C�oJ,�J
LICENSED CONTRACTORS DECLARATION DISTRICT NO. p PROCESSED BY
hereby affirm that I licensed under provisions Chapter GAS SYSTEM OUTLETS ✓ �O
9(commencing with Section 7000)of Division 3 of thee Business OUTLETS OVER
OS
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
fect. nQG HOSE BIB DATE 7- 7, a
License Nu e Lia Class
FINAL O
U
Contract 'fix Date BY O
I am exempt under Sec. U
e.sP.c. for this reasonUJ
Plan check fee y
Date: PLUMBING PERMIT ISSUING FEE$
(v 'Cld z
Signature TOTAL FEE _t
SINGLE FAMILY ^ '
HOME OWNER-BUILDER DECLARATION Plan check applicant I'1L=1. 'T
I hereby affirm that I am exempt from the Contractor's License Name 33034'�7'( t
Law for the following reason (Section 7031.5, Business and —yr•.
Professions Code): Address
❑ I, as owner of the property, will do the work and the City Tel. No. TOTAL 459 ® 5
structure is not intended or offered for sale(Section 7044, L^�:
Business and Professions Code). 41.E F
CHANGE Dirt
CONSTRUCTION LENDING AGENCY -
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued �(I_y111_(ihj,l Oy`1"_�r^
(Sec. 3097, Civ. C.).
LI
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby '
au tho e r presentotives of this County to enter upon the
ab a-men o d property r mspectia, rpo es.
/�/f- y . 9 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date