HomeMy WebLinkAbout1558A WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUIVI�BNG PERMIT
I hereby, affirm that I have a certificate of consent to self in- 20-0026 DPW 4/87
76A667A E ;
sure, or a certificafe of Workers'Compensation Insurance,or a CE 817(REV. 8/86)
certified copy ihereof (Sec. 3800, Lab. C.)
i �-->, ��-j���_� COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company /
� Certified copy is hereby furnished. ����� �� '`���
p FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ��� � ' '�� ����
� CerTified copy is filed with the county building ins ection ADDRESS
deparT ent. NUMBER FIXTURE OR�TEM @ FEE LOCALITY c �l � ��
Dafe � � Applicant WATER CLOSET(TOILET) NEAREST �
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CRo55 S7��ij�j7�jD�,1 �jJ�,�jf��?�/r �
COMPENSATION INSURANCE SHOWER �WN� 7 �_j "� � •�' �,,
(This section need not be completed if the work involved by MAIL `
the permit is for one hundred dollars (�100)or less.) LAVATORY ADDRESS � � �"'-'"'
� l�� /,�'/,r.� ,/ � �'f��� �tl
I certify that in ihe performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CITY����� � TEL N
f�Y".1��:�—�- ,�t�f �'~--r.�
as to become subject to ihe Workers'Compensation Laws. DISHWASHER
CONTRACTOR "'"l --
�i � �L�XG Ls� / �
Date Applicant CLOTHES WASHER
ADDRESS /�,��� ����_f��Vt y1, �, r
NnTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR `�� �T�-�-
`ion,you should become subject to the Workers'Compen- TC�� TEL NO.-
s. ,n provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM �������'c�� ���f ��7��'�G
ly wiih such provisions or this permit shall be deemed revok- � STATE .-�_ uC. — y/
ed. � � � � WATER HEATER LICENSE NOo�.-�� ��-� CLASS ��/
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of ihe Business OUTLETS OVER �� ���r'`�-�
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATIOFI
fed. / < �`
License Number����n���� Lic. Class�'^� DATE ��,��a� � �
Cn r`
FINAL
Coniracto� ._ �,�5 Date � l� BY t
� I am`ex mpt/UrYde�'�ec!���-' ���/�,�7 �
B.&P.C. for ihis reason Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ ,
Signature (� ��
TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempf from the Contractor's License Name " � ', '
Lr••� for the following reason (Section 7031.5, 8usiness and �
,���� i�,
ssions Code): Address
� I, as owner of the property, will do the work and the City Tel. No. � s .
� 4
structure is not intended or offered for sale(Section 7044, '
Business and Professions Code). �
CONSTRUCTION LENDING AGENCY 4 , ,#
I hereby affirm that there is a construction lending agency for `
the performance of the work for which this permif 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
rize representatives of ihis Counfy to enter upon ihe
abov mention �Qperiy for i�spection purposes.
�l �� � � �p SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig ature of Permia-�ee Da e