HomeMy WebLinkAbout9371WORKERS' 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 certified copy thereof (Sec 3800, Lab. C. )
Policy No. 5i� S Company
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspec-
tion department.
Date Applica y6 s
CERTIFICATE OF EXEMPTION PROM 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
sous to become subject to the Workers' Compensation Laws.
`e Applicant
fICE 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 Numb etr` Lic. Class_
Contractor Date
❑ 1 am exempt under Sec.
'B &P C forth'
COUNTY OF LOS ANGELES
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
NUMBER FIXTURE OR ITEM cr
WATER CLOSET c
BATH TUB
SHOWER
LAVATORY
SINK
DISHWASHER
CLOTHES WASHER
SWIMMING POOL RECEPTOR
LAWN SPRINKLER SYSTEM
WATER HEATER
GAS SYSTEM OUTLETS
OUTLETS OVER
5 PER SYSTEM
s reason
Plan check fee
Date:
Signature --PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER -BUILDER DECLARATION Name
i nereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
Professions Code): City
❑ 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 rpperty for inspection purposes.
ahaFO oxyl
Si nature or rermITTee Date
Tel. No.
BUILDING
ADDRESS
FEE
LOCALITY
NEAREST
CROSS ST.
OWNER
7 MAIL
ADDRE
CITY
SEE REVERSE FOR EXPLANATORY LANGUAGE
a
BUILDING AND SAFETY
TEL. NO.
CONTRACM
Ut) f
ADDRESS
I
CITY
TEL. NO.{P ,
STATE
LICENSE NO.(
r
DISTRICT NO.
O
FINAL )
DATE IJAZ.�®8(0
FINAL
BY ..
TEL. NO.
I
TEL. NO.{P ,
LIC.
CLASS ;
PROCESSED BY
VALIDATION 0
0
APPROVALS
UNDER SLAB WORK
ROUGH PLUMBING
GAS PIPING
GAS VENT
HOT WATER HEATER
PLUMBING FIXTURES
GAS TEST
UTILITY CO. NOTIFIED
DATE INSPECTOR'S SIGNATURE INSPECTOR'S MOTES
FINAL (!�:nier on
INDUSTRIAL
WASTE APPROVAL
INSPECTOR'S NOTES
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): 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 Low (Chapter 4 (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 apph-
cant to a civil penalty of not more than five hundred
dollars ($300).:
C3 I, as owner of the property will do the wort, 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 on owner of property
who builds or improves thereon, and who does such
work himself provided that such improvements are not
Infended 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