HomeMy WebLinkAbout6783AWORKERS' 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
f((Sgc.3Q00, Lab. C.)
PPolicy No.11'�1� dopa
ol�st'i`6t.
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspec-
tion department.
DoQ��te .» Applicant-
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CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he 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
Nr'TICE TO APPLICANT: If, after making this Certificate of
I :;tion, you should become subject to the Workers'
(-..,pensotion 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 um 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-yz/��� Lic. Closs
//1!
Contractor • � w I �f Dote
❑ 1 am exempt under Sec.
B-BP,C. for this reason
Date:
Signatu
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I by affirm that I am exempt from the Contractor's License
L -)r 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-menti.gned pro erty forigspe tion purposes.
f
Signature of Per 17ee - Date
76A667A
CE 817 (REV. 10/91 j
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
BUILDING
SS Z
fC
NUMBER FIXTURE OR ITEM
FEE
LOCALITY
WATER CLOSET
NEAREST
CROSS ST. 6'.rZ.7 C
BATH TUB
OWNER 'f- C rrMKi]r
SHOWER
LAVATORY
MAIL
ADDRESS /gi1 UrT
!Jr
SINK
CITY
/
TEL. NO iJ1 7
DISHWASHER
CONTRACTOR
CLOTHES WASHER
ADDRESS -22 4 Vr_
SWIMMING POOL RECEPTOR
CITY/C' L `�
.
'`
TEL NO. V,? '
T
LAWN SPRINKLER SYSTEM
C �1
STATiE
LICENSE NO.
LIC.
CLASS
WATER HEATER
DISTRICT NO.
t
6��
PROCESSED BY
GAS SYSTEM OUTLETS
OUTLETS OVER
5 PER SYSTEM
FINAL
DATE
FINAL
BY
,
VALIDATION
Plan check fee
PLUMBING PERMIT ISSUING FEE $ �dso
TOTAL FEE
Plan check applicant
Name
Address
City Tel, No,
SEE REVERSE FOR EXPLANATORY LANGUAGE
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LU
06
WItZ
APPROVALS DATE INSPECTOR'S SIGNATURE
UNDER SLAB WORK
ROUGH PLUMBING
GAS PIPING
GAS VENT
HOT WATER HEATER
PLUM13ING FIXTURES
GAS TEST
UTILITY CO. NOTIFIED �c77
FINAL enter on J�ront
INDUSTRIAL
WASTE APPROVAL
INSPECTOR'S NOTES
OWNER -BUILDER DECLARA.rIOhl
I hereby affirm That I om exempt from the Conlrocior
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 o permit subjects the appli-
cant to a civil penalty of not more than five hundred
dollars (5500).:
❑ I, 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 ac-
tor's License Low does not apply to an owner of p, ,.party
who builds or improves thereon, and who does such
work himself provided Shot such improvements are nol
intended or offered for sale. if, however, the building o;
Improvement is sold wifhtn one year of completion, the
owner -builder will have the burden of proving that he did
not build or improve for the purpose of safe.)
am exempt under Ser
B & P.C. for this reason
Owner