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WOR COMPENSATION
ate of consent to 76A668DPw9/89 APPLIWION FOR PLUMBING 'PERMIT
I hereby affirm th lave a certificate of consent to self insure, 76As87A
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.C.) '
�y�Q}I t COUNTY OF LOS,ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
Policy No. -7a id –""Company 1�11►'11ON WIVE , fN •
❑ Certified copy is hereby furnished. 1191! BUILDING
310/ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 5&Z I– 582 7 jZOSEM� f3L%/D
L� Certified copy is filed with the county building inspection
department. NUMBER FIXTURE OR ITEM ® FEE
� LOCALITY "I`>r M i-LE CITY
Date 4.72^91 1 Applicant WATER CLOSET S NEAREST
CERTIFICATE OF EXEMPTION FR M RKERS' CROSS sT. LAS T LN/>5 Dig
COMPENSATION INSURANCE BATH TUB
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.) LAVATORY7W 45OWNER C VJAAMpI OtJ ocFk/ELo?MEN T
I certify that In the performance of the work for which this permit s MAIL
Is issued, I shall not employ any person in any manner so as to SINK ADDRESS O OGi=A1�l C�/ii (o�Q
become subject to the Workers'Compensation Laws.
DISWASHER CITY LO W U &GAGI'I CA_ TEL.NO.e(.'?1-1,6049
Date Applicant CLOTHES WASHER CONTRACTOR
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 115dra SE-P. P.sizlGifl- AV& ,
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY I�Oa(�o $� TEL.NO. 2 ATE LIC. a
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER d3��� 0
(commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS IL CENSE NO. ��j CLASS c 6(e C
Professions Code,and my license Is in full force and effect. DISTRICT NO. PROCESSED BY
OUTLETS OVER
5 PER SYSTEM t
License Number �"9701� Lic.Class �� /
FINAL VALIDATION a
Contractor� - FINAL Z1 Ike- Date �}�ZZ1� ` � DATE _ j
4-q❑ -
cc
I am exempt under Sec. HOST` '�^
TI—If • BY
B.&P.C.for this reason
_ Date: Plan check fee C
Signature
PLUMBING PERMIT ISSUING FEE$ 1
❑ I OTAL FEE
SINGLE FAMILY Plan check applicant X11 D :r
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law ) ,a �_ _i
for the following reason (Section 7031.5, Business and Professions Address l [Ir �.tf.51l,
Cade):
❑ City L) Tel.No. n I ;,TES j
I,as owner of the property,will do the work and the structure _
is not intended or offered for sale(Section 7044, Business r2j U ��i t ��11 TOTAL AL :12 o 51D
and Professions Code). . , 1 i{e ro
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the CHANGE nCl�l
performance of the work for which this permit is Issued(Sec.3097.,
Civ.C.)
Lender's Name '1b ��►W k- 01� , Z � tae I]!�{�–: �i� ltf�
Lender's Address a3¢ co• �.7L► S 1 LPt 6584 ! Atit io 14
I certify that I have read this application and state that khe 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