The URL can be used to link to this page

Home My WebLink About0933A WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUM�IIVC� PERMIT f hereby, affiYm that I have a certificaTe of conseni to self in- 76A667A PW 4/87 sure, or a cerfifimte of Workers'CompensaTion Insurance,or a CE 817(REV. 8/86) � c rtifi d co thereof Sec. 3800, Lab. C.) � �'1��'��-r� �f� ��,,�/Q COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company � Certified copy is hereby furnished. �� '� FOR APPLICANT TO FILL IN(PRWT OR TYPE) BUILDING � � Certified copy is filed with the county building inspection ADDRESS � ��,V��/� dep�1 riment. NUMBER FIXTURE OR ITEM �a FEE 6 LOCALITY f , ,�� Date A � Applicant . WATER CLOSET(TOILET) NEAREST / CERTIFICATE OF EXEMPTION FROM WORKERS' 6ATH TUa CROSS ST.�f'.��p�ri/.Q � �.�^/Q COMPENSATION INSURANCE OWNER n � SHOWER � •``�.�*1'J \ � ,,�'i�( (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100) or less.) LAVATORY ADDRESS�( �, gr�4 I certify that in the performance of the work for which this per- mit is issued, I shall not em lo an erson in an manner so SINK P Y Y P Y CITY��,� f /� r ,�I�. o- � ��' as to become subjed to the Workers'CompensaYion Laws. DISHWASHER CONTRACTOR �� • �, � Date Applicant CLOTHES WASHER ' !CE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR ADDRESS /� � �,7� ` � �tion, you should become subject to the Workers'Compen- sation provisions of ihe Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM G CITY ��E� TE /,N `7�-�,/�� ly with Such provisions or ihis permit shall be deemed revok- `<� �T STATE LIC. ed. WATER HEATER LICENSE NO.� �� CLA55 LICENSED CONTRACTORS DECLARATION DiSTRICT NO. PRo SEo BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS � ^ �� ' �� g��>°�z��=a 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDAYIOiV �� fecL DATE `�" � License Number�� Lic. Class �� ,%�.�li �.�W�'J�' ��f-��4�'C ��CG.� Q, FINAL �: Coniractor Date ��7`�/ � BY '�.� �: � I am exempt under Sec. �� B.BP.C, for this reason � � Plan check fee � Date: PLUMBING PERMIT ISSUING FEE$ ,�1 �� Signature TOTAL FEE � i � SINGLE FAMILY plan check a licant HOME OWNER-BUILDER DECLARATION PP I hAreby affirm that I am exempt from the Coniractor's License Name for The following reason (Section 7031.5, Business and i ` F, .assions Code): Address � I, as owner of The property, will do the work and ihe City Tel. No. I s}ructure 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 t ihe performance of ihe 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 ihat 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-mention roperTy for i s e' n purposes �� , "----�--,/•�,_ �.�. SEE REVERSE FOR EXPLANATORY LANGUAGE � � Signature of Permittee Date