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WO
COMPENSATION a certificate
of consent to
20-W28 A0DPW e,e9 APPLI- ION FOR PLUMBING PERMIT
I hereby affirm e acertificate of consent to self Insure, ;
or a certificate of Worker's Compensation Insurance,or a certified
copy thereof(Sec..3800 Lab..C.) ;
1-BLOC, 009 i %;1 COUNTY OF LOS ANGELES • DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
Policy No. C mpany - NAT ����L'
��/ Certified copy Is hereby furnished. /V/V/ 1 BUILDING '
LTJ Certified copy is filed with the co it FOR APPLICANT TO FILL IN(PRINT OR TYPE)ction ADDRESS '32)0 3—15 50 7 Q(SSC M t/Lp
department. NUMBER FIXTURE OR R ITEM @ FEE LOCALITY •r)✓I.i j ELF_ C j TM
Date �ZZ ! Applican + WATER CLOSET `y317
NEAREST CROSS ST. LAS T uN AS t � y
CERTIFICATE OF EXEMPTION FRO WOR RS'
COMPENSATION INSURA CBATH TUB
E ASSESSOR
(This section need not be completed if the work Involved by the OWER MAP BOOK PAGE PARCEL
permit Is for one hundred dollars($100)or less.) OWNER CN�M'PIo N T�EVELl�7•PME'NT.
I.certify that in the performance of the work for which this permit LAVATORY
57,
Is Issued, I shall not employ any peyron4kany manner.so as to SINK ADDRESS 10 0 G A.-T E (p C)0
become subject to the.Workers'Compe sation
DISWASHER CITY Lis N(.� 1!;,GGN� (STEL.NO. 4W&046
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after makin thi Certificate of CONTRACTOR '
Exemption,you should become subject to the orke 'Compensation SWIMMING POOL RECEPTOR ADDRESS low, 4�f'T
provisions of the Labor Code,you must forth ith comply with such
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION WATER HEATER CITY � TEL.NO. 7 4.
I hereby affirm that I am licensed under provisions of Chapter 9
43,
(commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO. 3�j �- CLASS G�TE LIC. 0
Professions Code,and my license Is In full force and effect.
OUTLETS OVER DISTRICT NO. PROCESSED BY )_
5 PER SYSTEM..
License Number '�3(�, Lic.Class
FINAL VALIDATION lJJ
Contractors �N G r Date 'Z2-�j'1 DATE �,�� 1(L
❑ I am exempt under Sec. FINAL
B.&P.C.for th1 .7V^'-- e) 111
Plan check fee �--
Date:
Sign � � PLUMBING PERMIT ISSUING FEE$ -
❑ TOTAL FEE
7
Plan check applicant60
SINGL FAMILY 5
HOME OWNER-BUILDER DECLARATION NameI `b r r• -- g
I hereby affirm that I am exempt from the Contractor's License Law till:v I es
for the following reason'(Section 7031.5, Business and Professions Address j`07 110.50
Code):
❑ City Tel.No. ITEMS
I,as owner of the property,will do the work and the structure s
Is not Intended or offered for sale(Section 7044, Business BLt i Ltd W i(E to Poo. TOTAL �. .�
and Professions Code),
50
CONSTRUCTION LENDING AGENCY CHECK 110.511,
1 hereby affirm that there is a construction lending agency for the CAE .00
performance of the work for which this permit is issued(Sec.3097,
Civ.C.)
yrs ���A •.
Lender's Name 10rA1r��
Lender's Address iti4• G s�e Is a�rti 1 AM 10 i#
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