Loading...
HomeMy WebLinkAbout6832WORKERS' COMPENSATION DECLARATION 1 hereby,' affirm 'that I have a certificate of consent to self in- 76A666 DPW 4/87 sure, ora Certificate of Workers' CompensationCE 877 Insurance, or a CE 817 A (REV. 8/86) cerTifiedcopy herrn Seo.`38Q0, Lab. C.) Pohcy.'No., Company, L Certified copy,+is'hereby furnished. Certified copy is filed with the county building inspection department. �} Date Applicants_---L*y.� CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the work involved by the permit is for one hundred d6llars„(5100) or less.) I certify that in the performance of the work for which this per- mit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Dote Applicant 'CE TO APPLICANT: If, after making this Certificate of Ex- E__ption, you should become subject to the Workers: Compen- sation provisions of the Labor Code, you must forthwith comp- ly with such provisions or this permit shall be deemed revok- ed. LICENSED CONTRACTORS DECLARATION I hereby affirm that l 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 ef- fect. License NumberLic Class Contractor wife J F] I am exempt under Sec. '/3 A� B.&P.C. for this reason ' Date: :Signature SINGLE FAMILY HOME OWNER -BUILDER DECLARATION I -eby affirm that I am exempt from the Contractor's License For the following reason (Section 7031.5, Business and Pi essions Code): 1, 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 COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS 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 pr erty for inspection pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature ermittee Date FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING DRES 3�G' C L if /t� �- (t,l NUMBER FIXTURE OR ITEM @ FEE LOCALITY I} -A40 �g 6 4Q© WATER CLOSET (TOILET) �� NEAREST CROSS ST. 61 & d A) fl 1 JV (i Q BATH TUB SHOWER OWNER /V 4 e lV �` 1^6 w LAVATORY� d MAIL ADDRESS SINK /;;Z CITY TEL. NO. DISHWASHER aZ CONTRACTORZ—X j5;­Cfe, F CLOTHES WASHER ADDRESS A ./� SWIMMING POOL RECEPTOR CITY171 Ey fVCWV rig �C,,t on JM A P� tJ, LAWN SPRINKLER SYSTEM STATE / LIC. / LICENSE NO. D S� i CLASS —3 {e WATER HEATER GAS SYSTEM OUTLETS \ �-Z} DISTRICT NO. ,/� / PROCESSED BY OUTLETS OVER 5 PER SYSTEM FINAL DATE FINAL BY ► ALIDATION {�� - fl ..) f= G6,l c 6 7 I 8 4: 5 !� r, k ` h �4 Plan check fee PLUMBING PERMIT ISSUING FEE $ 6'� TOTAL FEE �-� Plan check applicant Name Address City Tel. No. 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 pr erty for inspection pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature ermittee Date APPROVALS DATE INSPECTOR'S SIGNATURE UNDER SLAB WORK ROUGH PLUMBING - — GAS PIPING GAS VENT NOT WATER HEATER PLUMBING FIXTURES GAS TEST UTILITY CO. NOTIFIED FINAL Ga%r ors 5ront INDUSTRIAL WASTE APPROVAL INSPECTOR'S NOTES INSPEC,TORS NOTES 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 requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions Of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Pro- fessions 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).. (,_t, as owner of the property will do the work, and 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 pr ,rty who builds or improves thereon, and who does suc. irk himself provided that such improvements are not intend- ed or offered for sale. if, however, the building or im- provement is sold within one year of completion, the owner -builder will have the burden of proving that he did r[ot build or improve for the purpose of sale.) I am exempt under Sec. S & P.C. for this reason Date Owner