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Home My WebLink About0934A WORKERS' COMPENSATION DECLARATION AppLICATIOfV FOR PLU1�A I NC� PERMIT I hereby,nffirm that I have a certificate of consent to self in- 20-0026 DPW 4/87 76A667A sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV, S/86) certified copy thereof (Sec. 3800, Lab. C.) �/ �_ Policy No.`�7S��J�'-�c3�C�ompany��9� .�C7'�l�L COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS � Certified copy is hereby furnished. � �� FOR APPLICANT TO FlLL IN (PRINT OR TYPE) BUILDING � Certified copy is filed with ihe county building inspection ADDRESS � � � � dep riment. NUMBER RXTURE OR ITEM @ FEE LOCALITY � � C�� WATER CLOSET(TOILET) �� Date Appl icant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' sATH TUB CROSS ST.��.qi/-�y � � COMPENSATION INSURANCE SHOWER oWNER ��,�.7,J�, �A ,c (This section need not be completed if the work involved by MAI� fhe permit is for one hundred dollars ($100) or less.) LAVATORY ADDRESS �l �� / I certify ihat in fhe performance of the work for which this per- SINK mit is issued, I shall not employ any person in any manner so CITYC+`��• � L!� ��'/fl'O� as to become subject to the Workers'Compensafion Laws. DISHWASHER CONTRACTOR "", /9 R L Date Applicant CLOTHES WASHER 'ICE TO APPLICANT: If, after making this Certificate of Ex- ADDRE55 , �l � (. SWIMMING POOL RECEPTOR �tion,you should become subject to the Workers'Compen- o `�3��-/ ` sation provisions of the Labor Code, you must forfhwifh comp- LAWN SPRINKLER SYSTEM � � CITY ,�pV`7��Qp, �N . �l/ ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. �(�� _ CLASS '� LICENSED CONTRACTORS DECLARATION DISTRICT No. PR CESSED eY I hereby affirm ihaT I am licensed under provisions of Chapter GAS SYSTEM OUTLETS � p` �/ �s i � -• 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER a@��=--- �'�--�- -- and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALI�ATI�� ` fect. DATE �` License Number��c� Lic. Class �.�� A>^e�°�!'� L.r��••.!�-�"`1/� ��Cj'�"�� BIY AL � Contractor � Date �� I am exempt under Sec � � � B.&P.C. for this �eason Plan check fee � � Date: PLUMBWG PERMIT ISSUING FEE$ ��b � Signature TOTAL FEE � ��, SINGLE FAMILY Plan check a limnt HOME OWNER-BUILDER DECLARATION PP� I hereby affirm that I am exempt from the Contractor's License Name ^ i C; for fhe following reason (Section 7031.5, Business and ' � .essions Code): Address � � I, as owner of the property, will do the work and the City Tel. No. , , structure is not intended or offered for sale(Seciion 7044, � � � Business and Professions Code). � CONSTRUCTION LENDING AGENCY I hereby affirm that there is a constr�ction lending agency for � �'� � E � � �� the performance of the work for which ihis 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 correcf. 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-meniion erty for inspectio urposes. � �� _� ��. �,�, SEE REVERSE FOR EXPLANATORY LANGUAGE � Signature of Permittee Date