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Home My WebLink About1554A WORKERS'COMPENSATION DECLARATION APPLICATION FOR LUIVI�IIVG PERMIT I hereb affirm that I have a certificate of consent to self in- 20-0026 DPW 4/87 -`; Y� 76A667A sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) ��? E certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS r Policy No.��'� Company:�T��T� ��(t.)/.� �� '/` � � Certified capy is hereby furnished. `�� FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING � � Certified copy is filed with the county building inspection ADDRE55 � �L� �')/� ��,%�,� NUMBER FIXTURE OR ITEM depariment. @ FEE LOCALITY ��`�� , Date � � 6 � Applicant WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CRoss ST��I/}j',Y)fj,q,/7 � .�1dj�,�- COMPENSATION INSURANCE SHOWER owNER�/��.`��,�� -�� _ � (This section need not be completed if the work involved by C`r the ermit is for one hundred dollars s100 or less. LAVATORY MAIL P � � � . ADDRESS,�� ( � `� �'� I cerfify fhat in the performance of the work for which this per- mit is issued, I shall not employ any person in any manner sa SINK CITy�,c-�� y7�� TEL. NO. ��,�� L�c`i / / [ as to become subject To the Workers Compensation Lpws. DISHWASHER — CONTRACTOR (�f� .��d'�-d_�f1y�� Date Applicant CLOTHES WASHER NnTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR ADDRESS ��`� j� �,: '�� `ion, you should become subject to the Workers'Compen- J a��:,��.i rE�. No. s_ �n provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM � �� 7�� r�� ._ ly with such provisions or this permit shall be deemed revok- STATE uC. ed. WATER HEATER LICENSE NO. �,"7�� ,� (� CLASS �`� �� LICENSED CONTRACTORS DECLARATION DISTRICT NO. PRo ESSED BY I hereby affirm that I am Iicensed under provisions of Chapter GAS SYSTEM OUTLETS 9(commencing with Section 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 V14LIDATION fect > � DATE ��=, License Number��t�<<'��' Lic. Class�'—�� ,/ FINAL Coniracio��E-c�7��eTe � �e� �� BY ��j.a 1f-%�.�s�3 i>-�Tl�.�.�ri<J�- ��}� � I am exempt under Sec. . B.&P.C. for this rea5or, Plan check fee Date: PLUMBING PERMIT ISSU�NG FEE$ � , Signature TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant _ ,,, ,_. I hereby affirm that I am exempt from the Contractor's License Name ' ^ , L��• for ihe following reason (Section 7031.5, Business and � c , < <. ' ssions Code): Address j o �,;; 'j (;,i; ,,'; � 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, �. 'j ,' Business and Professions Code). S CONSTRUCTION LENDING AGENCY `i � ; � I hereby affirm that there is a construction lending agency for the performance 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 application and state that the above information is correct. I agree to comply with all County � o�rdin ces and State laws regulating Plumbing, and hereby ' auihori representytiues of ihis County to enter upon the f/ above- entiqned�propert for inspection purp ses. i � � ��"f{��/; SEE REVERSE FOR EXPLANATORY LANGUAGE ` �.C�� :�•.� �, ,9 "�Y Sign ture of Permittee Dafe