HomeMy WebLinkAbout9357WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, ora certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lob. C. )
Policy NaL SLA Company Wit`-
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspec-
tion department.
DafeG Applicant( f7 -
CERTIFICATE OF EXEMPTION IOM 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.
Applicant
.ICE 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 Numbed�j Lic. Class_` 7:
ContractorQLLL�i� Date
❑ I am exempt under Sec.
B.&P.C. for this reason
Date:
Signature
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
i iereby 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 roperty for inspection purposes.
c,
Si nature of Permr ee Date
APPLICATION FOR PLUMBING PERMIT
76A667A
CE 817 (REV. 10/81)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
F' � L � Tom, P
SEE REVERSE FOR EXPLANATORY LANGUAGE
112
0
4�3
0
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
BUILDING
ADDRESS
NUMBER
FIXTURE OR ITEM @
FEE
-"
LOCALITY
WATER CLOSET r �
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NEAREST
CROSS ST.
BATH TUB %
SHOWER
OWNERL,41
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LAVATORY
!
MAIL
ADDRESS C
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SINK
CITYTEL,
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NO.. 2
DISHWASHER
CONTRALTOfyickj -,A
1
�ttfi
CLOTHES WASHER
ADDRESS
e
SWIMMING POOL RECEPTOR
CITY-
TEL. NO. "- j
LAWN SPRINKLER SYSTEM'-
�
STATE � "-
LICENSE NO. ±;
LIC.
CLASS 1
WATER HEATER
GAS SYSTEM �� OUTLETS /
-
/
DISTRICT NO.
t,r�
t C n
PROCESSED BY
�
OUTLETS OVER
5 P SYSTEM
FINAL
DATE
FINAL
BY
VALIDATION
i
(,
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Plan check fee
PLUMBING PERMIT ISSUING FEE $ }
TOTAL FEE
Plan check applicant
Name
Address
City Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
112
0
4�3
0
APPROVALS
UNDER SLAB WORK
ROUGH PLUMBING
GAS PIPING
GAS VENT
HOT WATER HEATER
PLUMBING FIXTURES
GAS TEST
UTILITY CO. NOTIFIED
INSPECTOR'S SIGNATURE
S NOTES
I hereby affirm that I am exempt from the Contractor's
License Low 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 permit to file a signed state-
ment that he is licensed pursuant to the provisions of the
Contractor's License Law (Chapter ® (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 oppli-
cant to a civil penalty of not more than five hundred
dollars ($500).:
❑ I, as owner of the property will do the war' nd
the structure is not intended or offered for sale.
(Sec. 7044, Business and Professions Code: The Contrac-
tor's License Law 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 that he did
not build or improve for the purpose of sale.)
I am exempt under Sec
B & P.C. for this reason
Owner