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hatIhoveacTIONDECLARATION APPLICATION FOR PLUMBING PERMIT
s I heieby{ affirm that I have o certificate of consent to self in- 776 66�A pV"4/87 n
sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) ,LJ
certified copy thereof (Sec. 3800, Lob. C.)
Policy N./00I Company 9i_L?X�t COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
1 4 Certified co hereby furnished.
SF1FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDIN
Certified copy is filed with the county building inspection ADDRESS Z,/
department NUMBER FIXTURE OR ITEM @ F LOCALITY
Date C t Appli< ��� ' WATER CLOSET(TOILET) a NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER Pil,05a
(This section need not be completed if the work involved by MAIL '
the permit is for one hundred dollars($100)or less.) / LAVATORY ADDRESyOp
11 vA11 fZ o,t/ j>,e
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CIT deiB��C J TEL NO.� T 973
as to become subject to the Workers'Compensation Laws. DISHWASHER �H�
CONTRACTOR7—G5
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRES$��1,3� S�G//sse CGe4r0 (J/t
SWIMMING POOL RECEPTOR
e tion,p,you should became subject to the Workers Co comp- CITY /Yaii � �Z TEL NO. fT
cation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC
ed. WATER HEATER LICENSE NO. 0_3 CLASS 43
LICENSED CONTRACTORS DECLARATION DISTRiCi NoOCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS J{^
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
feDATE O
d Professions Code, and my license is in full force and ef. 5 PER SYSTEM FINAL V (DATION y
License Number
yJ.3 o3 tic. Class
U
FI L y.
Til" l
Contractor y Date /'u B O
I am exempt under Sec. W
' to
B.BP.C. for this reason
lop.
2
Plan check fee
late:– PLUMBING PERMIT ISSUING FEE$ S � e e 3 0 .
98
Signature e
TOTAL FEE • • • 3 Q,5 0 5
SINGLE FA pion check applicant
HOME OWNER-BUILDER DEC ATIONI Q 0 5 $8
I hereby affirm that I am exempt from the Contractor's License Name
Low for the following reason (Section 7031.5, Business and
Professions Code): Address
I, as owner of the property, will do the work and the Cay Tel No.
structure is not intended or offered for sale(Section 7044,
Business and Professions Code).
CONSTRUCTION LENDING AGENCY PON.
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
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
authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
nature of P rrtti ee Dote