HomeMy WebLinkAbout0932A WORKERS'COMPENSATION DECLARATION APPLICATIOnI FOR �LUMBIIVC� P�RMIT
I here�y, affirm that I have a certificate of consent to self in- 76A667q PW 4/87 �
sure,or a certifimte of Workers'Compensation Insurance,or a CE 817(REV. 8/86)
cerfified copy thereof (Sec. 3800, Lab. C.) �.
Policy No°,%S`��SJD C�m�pany J'�z/�C.��(C`� COUNTY OF LOS AfVGELES DEPT. OF PUBLIC WORK,/S
� Certified copy is hereby furnished. � `� �
FOR APPLICANT TO fILL IN (PRINT OR TYPE) BUILDING
� Certified copy is filed with the county building inspection ADDRESS ��j �, S'�t1/���
NUMBER FIXTURE OR ITEM LOCALITY }
dep r}ment. @ FEE � , J� �
� ��� WATER CLOSET(TOILET) /�� 7�~ �
Date i '� Applicant NEAREST �`'
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST. C �I�/�f. ��
COMPENSATION INSURANCE SHOwER oWNER �� � �j��
(This section need not be completed if}he work involved by MAIL
}he permit is for one hundred dollars (�100)or less.) LAVATORY ADDRESS ��,Sl /�2�l�%,g
I certify ihat in the performance of the work for which this per- SINK
mit is issued, I shall noi employ any person in any manner so CITY � �� E� O.�j� , ��
as to become subject to fhe Workers Compensation Laws. DISHWASHER
. CONTRACTOR ��`,�.q ���5,� �^-'!�
-f�l(
Date Applicant CLOTHES WASHER ADDRESS �-l' �/r,4 �� • �
' 'ICE TO APPLICANT: If, after making This Certificate of Ex- SWIMMING POOL RECEPTOR
. �ion,you should become subject to the Workers'Compen- CITY ��'����� T /�
sation provisions of the Labor Code, you musi forfhwith comp- LAWN SPRINKLER SYSTEM p s-m��" i s�3
ly with such provisions or this permit shall be deemed revok- R'� STATE -i^/� f� uC. �r
ed: WATER HEATER LICENSE NO. J�{,y��G� CLASS a�
LICENSED CONTRACTORS DECLARATION �iSTRICT NO. PROC�S,ED BY
I hereb affirm that I am licensed under rovisions of Cha fer GAS SYSTEM OUTLETS �
Y P P L� �1���.�':`r`.-__,�.__._,_-w __
9(commencing wiih Secfion 7000)of Division 3 of ihe Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATIOW `�
fect a� DATE �
License Number-J���� Lic. Class �� �
/� ,�..� +� � FINAL � �
Contracto���2l�Ll1l�-g��Date� `" �'� BY �
� I am exempt under Sec. �
�
B.&P.C. for this reason m�
Plan che�ck fee � �
Date: PLUMBING PERMIT ISSUING FEE$ ��g �;�
Signature
TOTAL FEE �_ c �
SINGLE FAMILY Plan check a licant
HOME OWNER-BUILDER DECLARATION PP
I hereby affirm that I am exempt from the Coniractor's License Name r,
for the following reason (Section 7031.5, 8usiness and �-^
t assions 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(Section 7044, r ' ' . ` ��- ,
Business and Professions Code). �
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency fo� 'i � I r
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 enfer upon the
above-mentioned roperty for inspectio purposes.
, �h`-)._ �,� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date