HomeMy WebLinkAbout42732WORKERS' COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy there,of {Sec. 3800, Lab. C. )
Policy No. 201916 Company
Certified copy is hereby furnished.
.Certified copy is filed with the county building inspec-
tiondepartment.
Date alk Appligont tjN_U ;.
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.)
l 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:bECLARATION
Thereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my.license is in full force and effect.
License Number —Lic. Class
Contractor s aS: MS -14 % Date A
❑' I am exempt under Sec.
BAP.C. for this reason
Date:
Signature
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.).
"Lendeds 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 and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes.
Signature of Permittee Date
APPLICATON FOR PLUMWNG PERMIT
76A667A
CE 817 (REV. 10/81)
COUNTY OF LOS ANGELES
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
FIXTURE OR ITEM @ FEE
WATER CLOSET
BATH TUB
SHOWER
LAVATORY
SINK
DISHWASHER
CLOTHES WASHER
SWIMMING POOL RECEPTOR
LAWN SPRINKLER SYSTEM
WATER HEATER
GAS SYSTEM OUTLETS
Plan check fee
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
Plan check applicant
Name
Address
City Tel. No.
BUILDING AND SAFETY
BUILDING
ADDRESS �gfol d ens u a �wm.
LOCALITY
MAIL
CITY TEL., NO, t
5495
CONTRACTOR nerd r ion Co.
ADDRESS wili-s-t 8 XV4.
CITY 1 TEL aNQ. _2S41
STATE
LICENSE NO. I k1 All ?i , r--: , CLASS M ':5
pill
SEE REVERSE FOR EXPLANATORY LANGUAGE