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Nm that I'have a certificate
of consent to �BA687DPW 9189 HAIL®q KATION FOR PLUMBING PERMIT
I Ihereby affirm that I have a certificate o}consent to self insure, HAPPLICATION N>� 0F1
or a certificate of Worker's Compensation Insurance,or a certified
copy thereof(Sec.3800 Lab.C.)
Policy Ifo. / � Company _57A'1_& rUA)D COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
❑ Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING J
Certified copy is filed with the county building inspection ADDRESS L
department. ` NUMBER FIXTURE OR ITEM ® FEE LOCALITY
Date a ,f Applicant Ci /
WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
ASSESSOR
COMPENSATION INSURANCE
(This section need not be completed if the work Involved by the SHOWER MAP BOOK PAGE PARCEL
permit Is for one hundred dollars($100)or less.) WNER 4
I certify that in the performance of the work for which this permit LAVATORY
is issued, I shall not employ any person in any manner so as toA
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SINK D
RESS C t�
become subject to the Workers'Compensation Laws. '� J I O S -&.4A
DISWASHER CITY r I TEL.NO. ID 0YDate Applicant - e• CLOTHES WASHER NTRACTOR D
NOTICE TO PPLICANT: If, after making this Certificate of s s71.
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code,you must forthwith comply with such otf 71 It , kit r,• v
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY q TEL.NO. g �y }
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER 1�0 f(� g� �!0 b Q
(commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO. 3 7 S CLASS O
Professions Code,and my license is in full force and effect. OUTLETS OVER DISTRICT NO. PROCESSED BY
r5 PER SYSTEM Sr Q
License Number Lic.ClassFINAL
r v C U
.�., s� DATE _ L✓ VALIDATION 0.
W
Contractor C / Date '�/ flj
FINAL
I am exempt under Sec. BY ..
B.&P.C.for this reason
Date:
Plan check fee
PLUMBING PERMIT ISSUING FEF$ �
Signature ,..t �t —
❑ TOTAL FEE C� 3='-)' ITEMS
82 _55
F-1
SINGLE FAMILY Plan check applicant 1 ITE!iS
HOME OWNER-BUILDER DECLARATION Name T '•A. 82.95
1 hereby affirm that I am exempt from the Contractor's License Law I 882. q5
:� ark
for the following reason (Section 7031.5, Business and Professions Address X11+ v+ •'
Code): City Tel.No.
El
I,as owner of the property,will do the work and the structure
is not intended or offered for sale(Section 7044, Business
and Professions Code). ,^ r
9e/1jr ,O,y
CONSTRUCTION LENDING AGENCY r°hs i �I l�yo_
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
Pol-
and State laws regulating Plumbing, and hereby authorize
representatives of this County to enter upon the above-mentioned
property for inspection pur ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee �� Date