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DEC
v WORKER'have aENSATate of cLARATI to 7eA666DPW9,89 APPLICATION FOR PLUMBING PERMIT
• `' 7CA667A -
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab. C.)
�� T��uNQ COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
Policy No �Company
Certified copy is hereby furnished. BUILDING
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) gDDRESS �y
Certified copy is filed with the county building inspe tion
de artm nt. NUMBER FIXTURE OR ITEM @ FEE
G � /► LOCALITY
Date ✓ Applicant �✓ WATER CLOSET
NEAREST
CERTIFICATE OF EXEMPTIO ROM WORKERS' CROSS ST.
BATH TUB
COMPENSATION INSURANCE IASSESSOR
(This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) ) OWNER
I certify that in the performance of the work for which this permit / LAVATORY
is issued, I shall not employ any person in any manner so as toSINK MAIL .
become subject to the Workers'Compensation Laws. ADDRESS
DISWASHER CITY TEL.NO.
Date Applicant CLOTHES WASHER n
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR Q AIZ15
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ��!
provisions of the Labor Code, you must forthwith comply with such ADDRESS G i
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY 7 TEL.NO. c'✓ }
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER
(commencing with Section 7000) of Division 3 of the Business and STATE LIC. ?/
Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. 40 CLASS e
OUTLETS OVER DISTRICT NO. PROCESSED BY It
5 PER SYSTEM
License Number C Lic.ClassyDATE
VALIDATION LU
-144�
DATE •�
Contractor ate
❑ 1 am eZr4pt under Sec. / FINAL Z
BAP.C.for this reason
Plan check fee Q '
Date: r
Signature PLUMBING PERMIT ISSUING FEE$
❑ TOTAL FEE
SINGLE FAMILY Plan check applicant
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 Professions Address _
Code):
❑ City Tel.No. ,,-.-., a
1,as owner of the property,will do the work and the structure €�•t-€ =ff
is not intended or offered for sale(Section 7044, Businessand Professions Code). /� , "t r-`
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the :3
00
performance of the work for which this permit is issued (Sec. 3097, 3 l I N�
Civ. C.) S..Ht.K
Lender's Name IGE r
(_ �''
Lender's Address
I certify that I have read this application and state that the above , ,Ill�;0.1-0001, 9/1/0
information is correct. I agree to comply with all County ordinances _
and State laws regulating Plumbing, and hereby authorize 288 �
1 Ari 9:43
representatives of this County to enter upon the above-mentioned
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE