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Home My WebLink About1560A WORKERS'COMPENSATION DECLARATION AppLICATIOIV FOR PLIJMBInIC� PERnIIIT I hereby, affirm that I have a certificate of consent to self in- 20-0026 DPW 4/87 �J� 76A667A sure,or a certifimte of Workers'CompensaTion Insurance,or a CE 817(REV. 8/86) � � certified copy thereof (Sec. 3800, Lab. C.) ;�� Policy No. ` J"' Company_ �'�5?=✓��[.t�� COUNTY OF LOS ANGELES DEPT. AF PUBLIC WORKS � Certified copy is hereby furnished. ��"� �� FOR APPLICANT TO FIIL IN (PRWT OR TYPE) BUILDWG �) � Certified copy is filed with the county building inspection ADDRESS J�-j ��j; jj� /�/7 �• �� . � j departmeni. NUMBER FlXTURE OR REM @ FEE LOCALITY u �-�� , �C�L� r-��--- Date / /� � ApplicanT WATER CLOSET(TOILET) NEAREST�� CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST�,/ `f(� T � ,, /�� COMPENSATION INSURANCE sHowER owNER��y�� '�j� •— (This section need not be completed if fhe work imolved by MAIL fhe permit is for one hundred dollars (�100) or less.) �AVA7oRY ADDRES �y" j y' j� I certify that in the performance of the work for which this per- SINK mit is issued, I shall not employ any person in any manner so CITY� s � Vr/1 �� TEL N � � /1/' �1� G"t� as to become subject to the Workers Compensation Laws. DISHWASHER _� CONTRACTOR� �� - a � Date Applicant CLOTHES WASHER ADDRESS '' NOTICE TO APPLICANT: If, affer making this Cerfificate of Ex- c�� '� tion,you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR � �n rovisions of ihe Labor Code, ou must forthwith com CITY -��_,��}r� TE�.�07��;�� P Y P- / LAWN SPRINKLER SYSTEM � � f � ly with such provisions or this permit shall be deemed revok- �% STATE � / uC. � ,� ed. WATER HEATER LICENSE NO. � �-C�C��(� CLASS � `�� LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm ihat I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER '�!� -'�b�1 and Professions Code, and my license is in full torce and ef- 5 PER SYSTEM FINAL VALIDATION �' fect. -� .-� �, ��_i' ��Cr� Lic. Class G"-Z-� DATE � License Numbe� -n � � ,/ .,1 �` ,�, " FINAL � Contractor ��1c,i7� 4��N� �S BY �1�21��,��>�c_. °-�. : � � I am exempt u der ec. '�� B.&P.C. for this reasan , � � Plan check fee � Date: PLUMBING PERMIT ISSUING FEE$ � Signature TOTAL FEE � SINGLE FAMILY Plan check a licant HOME OWNER-BUILDER DECLARATION PP I hereby affirm that I am exempt from the Coniractor's License Name � '% `� �; (; �; ,''y Low for the following reason (Section 7031.5, Business and ' ssions Code): Address , , � I, as owner of the property, will do the work and the City Tel. No. r � structure is not intended or offered for sale(Section 7044, ' Business and Professions Code). _i CONSTRUCTION LENDING AGENCY , �� I hereby affirm that There is a construction lending agency for � �' " ' the perfarmance of ihe work for which ihis permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this applimtion and state that the above information is correcf. I agree to comply with al)County r in es and State laws regulating Plumbing, and hereby authorize represe ives �ihis County fo enier upon The above-m niioned roperi f9 inspection purposes. `'�f' ,�� ' �,/"� ,,� �'�- (� SEE REVERSE FOR EXPLANATORY LANGU�4GE i Signat re of Permitiee Da e