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WORIG pMPENSATIONDECLARATION 200026 DPW 9/89 ��®�I ��ype ®� PLUMBING
PERMIT �1
I hereby affirm that i nave a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.C)
Policy 0. 24e- Cogt 6 pang �� ��6 COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DI
101 Certified copy is hereby furnished. �Q ��
FOR APPLICANT TO FILL IN PRINT OR TYPE) BUILDING �
Certified copy is filed with the co i pection ( ADDRESS S � r,
department. p NUMBER FIXTURE OR ITEM ® FEE /r
Data ?/ / LOCALITY (J�.
Applica WATER CLOSET /dS �O NEAREST
CROSS ST.
CERTIFICATE OF EXEMPTION F OM WORKERS' BATH TUB ASSESSOR
COMPENSATION INSU ANCE
(This section need not be completed If the work Involved by the SOWER MAP BOOK PAGE PARCEL
IU
permit is for one hundred dollars($100)or less.) LAVATORY D-L, O O OWNE r( ,I ,
I certify that in the performance of the work for which this permit V MAIL
SINK L�O 1��
Is issued, I shall not employ any person in any manner so as to ADDRESS
become subject to the Workers'Compensation Laws.
DISWASHER CITY TEL.N .
Date Applicant CLOTHES WASHER CONTRACTOR pl��r_ 0��
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code,you must forthwith comply with such Thi If' ,
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY Lop TEL.NO.�? '
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER a
(commencing with Section 7000)of Division 3 of the Business and L� O LICENSE NO. LIC. "Uloe
C
Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS OCLASS C (,
- OUTLETS OVER DISTRICT NO. PROCESSED BY jZ
^� / 5 PER SYSTEM
License Number: _7334 7�'�� Lic.Class ���Cd �E � 14,1149.?
FINAL VALIDATION LL
Contractor ) , Data a Y DATE L ti 3�/i
"[ CrCL
garFINAL
I am exempt under Sec. FBY
I
B.&P.C.for this reason
Date: Plan check fee
Sign PLUMBING PERMIT ISSUING F
❑ TOTAL FEE
Plan Check a pli1 nl,,, r , r_ , ,/ tu��a$
SINGLE FA ILY P-. sum
HOME OWNER-BUILDER DECLARATION Name 3307 172.51,
1 hereby affirm that I am exempt from the Contractor's License Law :
for the following reason(Section 7031.5, Business and Professions Address 1 T EMS
Code):
El 1,
qeo�p�
I.N - I I TAL 172.50
I,as owner of the property,will do the work and the structure
isnot Intended or offered for sale(Section 7044, Business C•NE,..Y 172.50
C
r
and Professions Code). �� .00CONSTRUCTION LENDING AGENCY �/f/7 1 !rv��LiI
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit Is issued(Sec.3097, O+ t^+ L%I x,. 'JI011� �_j�, 11/14/90
Civ.C.) f 00
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Lender's Name C'1 '' f-- 1_` ° 3822 1 PN 4 e rt•
Lender's Address ° r 1 t�.•� ��� f 1
I certify that I have read this application and state that a above ).
information is correct. I agree to comply with all County ordinances r
and State laws regulating Plumbing, and hereby authorize x, -P., 4,
representatives of this County to enter upon the above-mentioned r tl tri
property for Inspection purposes. SEE REVERSE FOR EXPLAII6`r4'Y LANQUA (.—J
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