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WI7RIrER'S COMPENSATION DECLARATION 200026 DPW9/89Y �jB®g O�p�B®9�5 ®� �Lt�6V1®IEt7VJ ��AOIH9��
I here affirm that I have a certificate of consent to self insure;. _
ora ` rf,gate of Worker's Compensation Insurance, or a certified -_
copy 7tie eof(Sec'3800 Lab'C)
COUNTY'OF LOS ANGELES DEPT OF PUBLIC WORKS, DEPT.OF PUBLIC WORKS DIV.
Policy No Company
Certified copy is hereby furnished
•' $ _ FOR APPLICANT TO FILL IN(PRINT OR TYPE) a CJ 4S2 �•�/'!''i fl vG
^ ❑ BUILDING
Certified copy is filed w,th•the county building'inspection ADDRESS'
department NUMBER FIXTURE OR ITEM - ® FEE =-
__ LOCALITY
Date ` r ` � Applicant ; WATER CLOSET
1 f NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'' BATH TUB CROSS ST<
f /• - ��-•'" _ •i-,
COMPENSATION INSURANCE ASSESSOR
(This'section need not be completed if the work involved by the SHOWER MAP BOOK .� PAGE PARCEL
permit«is for one hundred dollars($100)or less.) OWNER
r , .�. LAVATORY'='_ - -, k..
I certify that in the performance of the work for which this permit -
is issued, I shall not employ any person•in any manner so as to - SINK ) MAIL S4�L G - vE•
ADDRESS
become subfe t to the Workers'compensation,Law
DISWASHER CITY TEL NO
f�, alta
Date,�d A t j/ LC/yy — t/-�/ LC e/ y
P ! CLOTHES WASHER
NOTICE O A PLICANT If, after making Ahis Certificate of _ CONTRACTOR S pL��T17y�` CrQ.
Exemption;,you'shouId.becom6 subject to the Workers'Compensation SWIMMING POOL RECEPTOR A A e/y�� �/
provisions of the,Labor.Code, you.must forthwith comply with such ADDRESS �¢�jl ��/ 'L C /TJ ,' �jLt//�/�
provisions or this permit shall be deemed revoked •r LAWN SPRINKLER SYSTEM T !�
LICENSED CONTRACTORS'DECLARATION CITY lG.1t1/ C- C71T V TEL NC�!}�,_75W }
I hereby affirm that I am licensed under provisions of Chapter 9- WATER HEATER. d
STATE
(commencing with-Section 7000) of Division 3 of the Business and ' GAS SYSTEM OUTLETS IC NSE NO ���7 L ( 0
Professions Code,and my license is,n full force and effect
OUTLETS OVER DI PR E E B _ Q
5 PER SYSTEM 0
License Number �V; _ / L,c Class 2
/i 7LM� �tg VVV 1 U
(_!� hl. FINAL'` LI ATION w
�j / 2 DATE i ''�� a
Contractor �/" / i �lB/i1/(� Date ` ✓� « (n
I am exempt under,Sec t BY AL Z
B&P C for this reason '
' Date Plan check fee
Signature PLUMBING PERMIT ISSUING FEE$ G� 9
❑ ;_. TOTAL FEE
t Plan check applicant
FAMILYSINGLE
HOME OWNER-BUILDER DECLARATION ' Name W.t T. ' x
I hereby affirm that I am exempt from the Contractor's'License Law _ ,-7
for the follow,ng`reason'(Section 7031 5, Business and Professions Address 7- _ �J{'`l
Code) ' �T` �
Eli • City. Tel No '
I,as owner of,the property,will do the work and the structure t�
0
- f
' is not intended or offered for sale (Sectiorn 7044, Business � - _. - I-I I AL _g 0- _e_
and PFofess,ons Code) _r ® '+, - s
CONSTRUCTION LENDING AGENCY (;IlA;hE
I hereby affirm that there is a construction,lending agency for the
performance of the work for which this permit ,s issued (Sec 3097, r -- f
Civ c) 'W/31!'3t I
d 1.to i h3
Lender's Name
d� y
i.�
- V
Lender's Address
I certify that I have read this application'and state that the above ;® `
information ,s correct I agree to comply with all County,ordinances
and State laws regulating Plumbing, and hereby-authorize -- -- -- '
representatives of this County to enter upon the above-mentioned
property for inspection purposes '
SEE REVERSE FOR EXPLANATORY LANGUAGE