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Home My WebLink About9156AWORKERS' COMPENSATION DECLARATION I hereby, affirm that I have a certificate of consent to self in- sure, or a certificate of Workers' Compensation Insurance, or a ort'fied_hereof (Sec. 3800, Lab. C..) W-(_4q 1qk aIV"9 y • Company Certified copy is hereby furnished. Certified copy is filed with the county building inspection departure `�' _ - sl Date " Applicant �t 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 per- mit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. r Date Applicant NS'T''E TO APPLICANT: If, after making this Certificate of Ex- e( )n, you should become subject to the Workers' Compen- sat—i 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 I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business 20-0026 DPW 4/87 APPLICATION PERMIT 76A667A CE 817 (REV. 8/86) �€ COUNTY OF LOS ANGELES FOR APPLICANT TO FILL IN (PRINT OR TYPE) NUMBER FIXTURE OR ITEM @ WATER CLOSET (TOILET) BATH TUB SHOWER LAVATORY SINK DISHWASHER CLOTHES WASHER SWIMMING POOL RECEPTOR LAWN SPRINKLER SYSTEM WATER HEATER GAS SYSTEM OUTLETS OUTLETS OVER and Professions Code, and my license is in full force and ef- 1 5 F f _ ect. License Number '7 /u✓�% �Liicc. Class %//7 ControctorC1-te igP3f- I am 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 Lav 'ter the following reason (Section 7031.5, Business and Pna, ions 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-m ntioned property for inspection purposes. Plan check fee PLUMBING PERMIT ISSUING FEE $ TOTAL FEE Plan check applicant Name Address City Tel. No. BUILDING ADDRESS FEE LOCALITY NEAREST CROSS ST OWNER MAIL ADDRESS CITY CONTRACTOR ADDRESS 1) TEL. NO. litlctf, ' I-.L_ C CITY �f/f�.) TEL. NO.STATE!-f�� ' g LICENSE NO. "i 3111Vd DISTRICT NO,, CLASS l PROCESSED BY FINA TEL FINAL BY VA ATION Q tom€ t T ,a x3 6 5 P a -22 0 '� "7 — i <= G� � �} uS 0 c. L ti 6, 2 'L 8 8 SEE REVERSE FOR EXPLANATORY LANGUAGE J Signature of Perm 4Ae' Date APPROVALS DATE INSPECTOR'S SIGNATURE UNDER SLAB WORK ROUGH PLUMBING GAS PIPING GAS VENT HOT WATER HEATER PLUMBING FIXTURES GAS TEST UTILITY CO. NOTIFIED FINAI- efater On 3P0121 INDUSTRIAL WASTE APPROVAL INSPECTOR'S NOTES INSPECTOR'S NOTES OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's a 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 w...,.'_ 'F. I- n11a 4 fin A. —Ai 1.#1— ni S®^firm 7031.5 by any applicant for a permit subjects theappli- cant to a civil penalty of not more than five hundred dollars ($500).. ❑ 1, 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 property who builds or improves thereon, and who does su 'ork himself provided that such improvements are not ind- 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 not build or improve for the purpose of sale.) I am exempt under See. P.C. for this reason Date Owner