HomeMy WebLinkAbout4053AWORKERS' 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 NoJ `" .Y - Company
Certified copy is hereby furnished,
❑ Certified copy is filed with the county building Inspec-
ilon department.
Date Applicant
CERTIFICATE OF EXEMPTION FROM 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 ony 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 sub'lect to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such pravislona 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.0 for this reason
Signatu
Date
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Low 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 Cade).
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 f 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
obove-mentioned property;>for:Xr`I"spection purposes.
Signature of Permittee Date
76A667A
CE 817 (REV- 10/e1 )
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
BUILDING AND SAFETY
FOR APPLICANTTO FILL IN (PRINT OR
TYPE)
BITMING
ADDRESS `t
NUMBER FIXTURE OR ITEM
C
FEE
LOCALITY 7 � .y
- '
WATER CLOSET
NEAREST
CROSS ST. r
BATH TUB
OWNER
SHOWER
LAVATORY
MAIL
ADDRESS
SINK
CITY r , TEL. NO.
DISHWASHER
CONTRACTOR .
CLOTHES WASHER
ADDRESS
SWIMMING POOL RECEPTOR
CITY 7EL, NO.
-
LAWN SPRINKLER SYSTEM
STATE CIC.
LICENSE NO. CLASS
WATER HEATER
DISTRICT NO.
PROCESSED BY
GAS SYSTEM OUTLETS
OUTLETS OVER
5 PER SYSTEM
FINAL VALIDATION
DATE
FINAL
BY
,
_
r •, r r i.
Plan check fee
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
Plan check applicant
Name
Address
City Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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