HomeMy WebLinkAbout1197AWORKERS' COMPENSATION DECLARATION
I hereby, affirm that 'I'have a certificate of consent to self in-
sure, or a certificate of Workers' Compensation Insurance, or a
certified copy thereof (Sec. 3800, Lab. C.)
Policy No. )�� 991,a Company, 554M40— t�..,P
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection
4� department. -
Date /Aprqlzllz���
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so
as to become subject to the Workers' Compensation Laws.
Date Applicant
t ` E TO APPLICANT: If, after making this Certificate of Ex-
e. aon, you should become subject to the Workers' Compen-
sation provisions of the Labor Code, you mustforthwith comp-
ly with such provisions.or this permit shall be deemed revok-
ed.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that,I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and ef-
fect.
License Number vat 1030 Lic. Class C r3� 7,
Contractor5TT6tt 'S ate > ql'3Q" Fo
I am exempt under Sec.
B.&P.C, for this reason
Date:
Signature
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I H-reby affirm that I am exempt from the Contractor's License
=for the following reason (Section 7031.5, Business and
F, _,-essions Code): ,.
OI, as owner of the property, will do the work and the
structure 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
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 enter upon the
Aove-mentioned properlyAor inspection purposes.
20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT
76A667A
CE 817 (REV. 8/86)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
BUIDRELDING.T<� y l B 6
SS AD
NUMBER
FIXTURE OR ITEM
@
FEE
LOCALITY
' d Z
WATER CLOSET (TOILET)
NEAREST
CROSS ST.
BATH TUB
SHOWER
OWNER
�4 <
LAVATORY
AD L
ADDRESS
SINK
CITY L TEL. NO.
DISHWASHER
CONTRACTOR
i
CLOTHES WASHER
ADDRESS P fQ /
SWIMMING POOL RECEPTOR
CITY TEL. NO. S'�
2
LICENSE NO. a / t3 fl CLASS C
DISTRICT NO. PRO SED BY
y Y
DATE EL /' VALIDATION 0.
FINAL '�J)� � ((//
BY O
F-
V
W
rs
, H
z
- 1 1 9, 7 A
yj
ff a gi a B ♦I
( 1 6 0
_
r, 0,,
0 B 2 6 O
LAWN SPRINKLER SYSTEM
WATER HEATER.
GAS SYSTEM OUTLETS
OUTLETS OVER
5 PER SYSTEM
ev,O
Plan check fee
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
Plan check applicant
Name
Address
City Tel. No.
113
ignatu& ofo6rmittee r r Date
SEE REVERSE FOR EXPLANATORY LANGUAGE