HomeMy WebLinkAbout5497WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a cer'tificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
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Policyolicy No. Company
Certified copy is hereby furnished.
Certified copy is filed with the co ty building inspec-
tion de artment.
Date Applicant �LLr
CERTIFICATE OF EXEMPTIO FROM RKERS'
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 my license is in full force and effect.
License Number 6) l ® Lic. Class
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❑ I am exempt under Sec.
B.&P.C. for this reason
Date:
Signatu
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 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-mtioned property for inspection purposes. p
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Signorre of Perrriittee Dat
76A667A
CE 817 (REV. 10/81)
APPLICATION PLUMBING PERMIT
COUNTY OF LOS ANGELES BUILDING'AND SAFETY
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
BUILDING
ADDRESS /� /V.-
NUMBER FIXTURE OR ITEM @
FEE
LOCALITY • aMLt',oa-3 7( -3 -
WATER CLOSET
NEAREST
CROSS -
BATH TUB
OWNER (/ ��V
SHOWER
LAVATORY
MAIL
ADDRESS
SINK
CITY TEL. N� -
DISHWASHER
CONTRACTOR V/e
CLOTHES WASHER
ADDRESS t0
SWIMMING POOL RECEPTOR
CITYfes." TEL.
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LAWN SPRINKLER SYSTEM
Y,/
STATE CENSE NO. ref f / 7' CLASS
WATER HEATER
DISTRICT NO.
f Lt
PROCESSED BY
GAS SYSTEM OUTLETS
OUTLETS OVER
5 PER SYSTEM
FINAL 71 , r _ VALIDATION
DATE ✓ J
FINAL
BY
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Plan check fee
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE ? e57Z�
Plan check applicant
Name
Address
City Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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LA
APPROVALS DATE INSPECTOR'S SIGNATURE
UNDER SLAB WORK
ROUGH PLUMBING
GAS PIPING
GAS VENT
HOT WATER HEATER
PLUMBING FIXTURES,
GAS TEST
UTILITY
TILITY CO,��OTIIIED
FINAL
INDUSTRIAL
WASTE APPROVAL
INSPECTOR'S NOTES
INSPECTOR'S NOTES
OWNER -BUILDER DECLARA110N
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5,
Business and Professions Code): Any city or county which
requires a permit to construct, alter, improve, demolish,
or repair any structure, prior to its issuance, also re-
quires the applicant for such pe", it to file a signed sfate-
ment that he is licensed pursuant to the provisions of the
Contractor's License Low (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 of Section
7031.5 by any applicant for a permit subjects the appli-
cant to a civil penalty of not more than five hundred
dollars ($500).:
El f, as owner of the property v,,ill do the work, and
the structure is not intended or offered for sale.
(Sec. 7044, Business and Professions Code: The Contrac-
tor'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 at
Improvement is sold within one year of completion, the
owner -budder will have the burden of proving that he did
not build or improve for the purpose of sale.)
I am exempt under Sec,
B & P.C. for this reason
Owner