Loading...
HomeMy WebLinkAbout6586WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers' Compensation Insurance, CE 817 (REV. 10/81) or a cc%rI ieyd copy thereof (Sec. 380f0,, �L,aab.. C.) PolicyNo.—Cam y �� ✓��pany �/Y�r� �(��Gek ❑ Certified copy is hereby furnished. Certified copy is filed with the county building inspec- tion department. P ate Applicanh _coq" tsx_5 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the work involved by the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers Compensation Laws. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and t /my license is in full force and effect. License Number 25 3 i"-30 � Lic. Class (C�3 Contractor616C�9 � 309'" Date Lf—"_ I am exempt under Sec. B.&P.C. for this reason Date: Si SINGLE FAMILY HOME OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code): ❑ 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). CONSTRUCTION LENDING AGENCY 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 appI'cati0 and state that the above information is correct. I ogre comply with all County ordinances and State laws re ating Plumbing, and hereby authorize re entatives this County to enter upon the a me d pro rty for inspection purposes. Signature of Permittee Date APPUCAflON FOR PLUMBING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ADDRESS NUMBER FIXTURE OR ITEM @ FEE qy� LOCALITY WATER CLOSET NEAREST �A CROSS ST. BATH TUB SHOWER OWNER ,/�► y� ,ems LAVATORY MAIL ADDRESS G� SINK CITY TEL. A (Z� f� TEL. NO. 6 DISHWASHER CONTRACTOR CLOTHES WASHER ADDRESS �c) � �'Y � � �,' (�y'��,. SWIMMING POOL RECEPTOR CITY �✓ � �� � TEL. NO.q J? –3-0 LAWN SPRINKLER SYSTEM TATE LIC. LICENSE NO. `� CLASS C� WATER HEATER GAS SYSTEM OUTLETS DISTRICT NO. f PR ESSED BY �` OUTLETS OVER 5 PER SYSTEM FINAL VALIDATION DATE FINAL BY , i,. Plan check fee PLUMBING PERMIT ISSUING FEE $� TOTAL FEE Plan check applicant Name Address City Tei. No. SEE REVERSE FOR EXPLANATORY LANGUAGE APPROVALS DATE INSPECTOR'S SIGNATURI UNDER SLAB WORK ROUGH PLUMBING GAS PIPING GAS VENT HOT WATER HEATER PLUMBING FIXTURES GAS TEST UTILITY CO. NOTIFIED FINAL �iafer oew }sant T' INDUSTRIAL WASTE APPROVAL INSPECTOR'S NOTES INSPECTOR'S NOTES OWNER -BUILDER DECLARA710iN I hereby affirm`ihat I am exempt from the Contractor':: License Low for the following reason (Section 7031.5, Business and Professions Code): Any city or counfy,whlch requires a permit to construct, olier, improve, demolish, or repair any structure, prior to its, issuance_ also re- quires the 6pplieont for such permit to file d signed stain- ment that he is licensed pursuant to the provisions of the• Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Profes- sions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation or Section 7031.5 by any applicant for a permU subject:; the appli- cant to a civil penalty of not more than five hundred dollars ($500).: © I, as owner of the property will do the work, and the structure is not intended or offered for sale. (Sec. 7044, Business and Professions Code: The Contrac- foP's License Low does not apply to an owner of property who builds or Improves thereon, and who does such work himself provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving ihaf he did not build or improve for the purpose of sale.) I am exempt under Sec. ' B & P.C. for this reason 0 Owner