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t1hu COMPENSATION DECLARATION APPLICATION FOR PLUMBING P9RMIT {�
I hereby affirm that I have'o certificate of consent to self in 7�A7 DPW 4/87 �J
sure or a cenif[coteof Workers Compensation Insurance or a CE 817(REV 8/8e)
certified cropy thereof (Sec 3800 Lob C )
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy No L!��rampany
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILD ING
deport copy is filed with the county building inspection ADDRESS �'34 �j.
IQ depart enc NUMBER FIXTURE OR ITEM Q FEE LOCALITY
Do;. [cant WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMP FROM WORKERS BATH TUB CROSS ST _ t C
COMPENSATI NSURANCE SHOWER OWNER
L (Thls section need not be completed If the work involved by MAIL y /�-
the pertnit Is for one hundred dollars($100)or less ) LAVATORY ADDRESS L.6
1 I certify that in the performance of the work for which this per SINKTEL
mit Is[saved I shall not employ any person in any manner so CITY" 07 4n_x 70`t
as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR
Dote Applicant CLOTHES WASHER, ADDRESS y_s
'4. ��
NOTICE TO APPLICANT If after making this Certificate of Ex SWIMMING POOL RECEPTOR L,T
emption you should become subject to the Workers Compen- CITY 00J3 L
sation provisions of the Labor Code you must forthwith comp LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok SLATE LIC
ed WATER HEATER LICENSE IN 40L. 2O
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affirm that I licensed under provisions Chapter GAS SYSTEM OUTLETS v.0
9(commenting with Section 7000)of Division 3 of thea Business OUTLETS OVER
and Professions Code and m license is in full force and of 5 PER SYSTEM FINAL Y
I feC' _ y - eo to DAT 1 VALIDATION a
! e• W .�
License Number D L[c Class e 3 O U
Q �j7 O
Coneactor Dote BY `97 It-
am exempt under Sec )�j
B 8P C for this reason Plan check fee O00 ► ( 1 > 3307gD,IIU�
Dot —_ PLUMBING PERMIT ISSUING FEE$ ^
Signature 1 TOTAL FEE Q DEM
GLE FAMILY Plon check applicant TOTAL 40 - O0
HOME R-BUILDER DECLARATION CHECY� WJ•UU
hereby off um th t m exempt from the Contractor s License Name i
Low for the follo nq reason (Section 7031 5 Business and CHANGE
Professions Code) Address '
1 as owner of the property will do the work and the City Tel No
structure is not intended or offered for sale(Section 7044 I]QI]{]-0001 -91-:719 1
Business and Professions Code) -
CONSTRUCTION LENDING AGENCY , S "b 1 �"
I hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit is issued
(Sec 3D97, Gv C ) _
pp 7C f.l r.
Lender s Nome --i O D �1 --i
i Gi r i-• �F
Lender s Address rsl H
O i
I certifyi that I have rood this epee to
and state that the , Lv1
above information rs correct I agree to comply with all County �' 3
ordinances and State laws regulating Plumbing and hereby
authorize representatives of this County to enter upon the b 1
above-mentioned property for inspection purposes - =. _
!?/L 7/1 / SEE REVERSE FOR EXPLANATORY LANGUAGE wi C L J [r
Signai.4ilk of Permittee Dote • y,y