HomeMy WebLinkAbout1196A+ WORKERS' 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. 262962Company 's C—.a"'4 11,6,
❑ Certified copy is. hereby furnished.
Certified copy is file with the county building inspection
department. ��q
Date Appli nt J
CERTIFICATE OF EXEMPTION FROM ORKERS'
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 becojne subject to the Workers' Compensation Laws.
Date Applicant
r. CE TO APPLICANT: If, after making this Certificate of Ex-
e, oon, you should become subject to the Workers' Compen-
sation provisions of the Labor Code, you must forthwith 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 YCR / 0 Q Lic.
ContractorZA32 dS ate
am exempt under Sec.1:
B.&P.C. for this reason
Signature
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I.b^reby affirm that I am exempt from the Contractor's License
I _':For the following .reason (Section 7031.5, Business and
F,_,essions Code):
I, 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
above -mentioned property for inspection purposes.
Signa �Permit Date
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)
BUILDING�' ADDRESS Q
NUMBER
FIXTURE OR ITEM
@
FEE
LOCALITY
WATER CLOSET (TOILET)
NEAREST
CROSS ST. -
BATH TUB
SHOWER
OWNER
e
LAVATORY
MAIL
ADDRESS
SINK
CITY
DISHWASHER
CONTRACTOR
CLOTHES WASHER
ADDRESS ,
SWIMMING POOL RECEPTOR
CITY � ® %
/Z ,
LAWN SPRINKLER SYSTEM16
STATE
LICENSE NO. ,i(
WATER HEATER
GAS SYSTEM OUTLETS
DISTRICT NO.
OUTLETS OVER
5 PER SYSTEM.
FINAL
DATE
FINAL
BY
Plan check.fee
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
Plan check applicant
Name
Address
City'. Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
MIM
TEL. NO. `'
TEL. NO. 7 ��
LIC.
CLASS C —
PR ESSED BY
V A I Ir%A TJ^k1
<,119,6A
• • a � 0 t)
� r-
I - 1 650
• a f?,
0 a 2 6 — 8