HomeMy WebLinkAbout0439WORKERS' COMPENSATION DECLARATION
I hereby affirm that I -have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C. )
Policy No. Company
ElCertified copy is hereby furnished.
❑ Certified copy is filed with the county building inspec-
tion department.
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involvgd 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 Lic. Class
Contractor
❑ I am exempt under Sec
B.&P.C. for this reason
Date
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.).
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-mentioned property for inspection purposes.
Signature of Permittee Date
APPLICATION FOR PLUMBING PERMIT
76A667A
CE 817 (REV. 10/81)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
BUILDING
ADDRESS
NUMBER FIXTURE OR ITEM @
FEE
LOCALITY
WATER CLOSET
NEAREST
CROSS ST.
BATH TUB
OWNER
SHOWER
LAVATORY
MAIL
ADDRESS
SINK
CITY
TEL. NO.
DISHWASHER
CONTRACTOR
CLOTHES: ASt 1i
ADDRESS
SWIMMING POOL RECEPTOR
CITY
TEL. NO,
LAWN SPRINKLER SYSTEM
STATE
LICENSE NO,
LIC.
CLASS
i WATER HEATER
DISTRICT NO.
PROCESSED BY
GAS SYSTEM OUTLETS
OUTLETS OVER
5 PER SYSTEM
FINAL
DATE
FINAL
BY
VALIDATION
q..:
vv ;
..
t. et W
�,J
Plan check fee
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
Plan check applicant
Name
Address
City Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE