HomeMy WebLinkAbout4253AWORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or n certificate of Workers' Compensation insurance, or a i_ertified copy thereof (Sec. 3800, Lab. C.) Policy No. Company Certified copy is hereby furnished. ❑ Certified copy is filed with the county building inspec- tion 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 any 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 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 Number Lic. Class Contractor Dote 1 om exempt under Sec. B.&P.C. for this reason Date: Signature SINGLE FAMILY HOME 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): ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sole (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 lows regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. Signature of Permittee Date 76A667A CE 817 (REV. )0/81 APPLICATION FOR PLUMBING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY SEE REVERSE FOR EXPLANATORY LANGUAGE FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING _ ADDRESS NUMBER FIXTURE OR ITEM na FEE LOCALITY WATER CLOSET NEAREST CROSS ST. BATH TUB OWNER PRESLEY CO, SHOWER LAVATORY MAIL A600 CAI II ADDRESS NEWPORT BEACH, CA SINK CITY TEL. NO, • DISHWASHER CONTRACTqWAEEyyAY pL UMlB;NG $ HEATING INC. CLOTHES WASHER 13605 E. IMPERIAL H115HWAY ADDRESSSANTA FE SPR1,11 , CA 90670 SWIMMING POOL RECEPTOR CITY TEL NO. LAWN SPRINKLER SYSTEM STATE LIC. LICENSE NO. CLASS WATER HEATER DISTRICT NO PROCESSED BY GAS SYSTEM OUTLETS OUTLETS OVER 5 PER SYSTEM FINAL VALIDATION DATE FINAL BY ► Plan check fee PLUMBING PERMIT ISSUING FEE $ TOTAL FEE Pion check applicant Noma Address City Tel. No. SEE REVERSE FOR EXPLANATORY LANGUAGE