HomeMy WebLinkAbout0047AWORKERS' 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. c3800, Lab. �C^. )
Policy N4. 9` Company: (,r4
Certified copy is hereby furnished.
Certified copy is filed with the count building in ection ,
department. 4
Date '`+x Applicant
CERTIFICATE OF. EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE
(This section need not be completed i£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
I" -ICE TO APPLICANT: If, after making this Certificate of Ex -
ion, you should become subject to the Workers' Compen-
sanon 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 fQ S P Lic. Class 2—
Contractor 24/+U Erb J Date
I am. exempt under Sec.
B.&P.C, for this reason
Date:
Signature
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
L -'or the following reason (Section 7031.5, Business and
F sions 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
authorie re pre t tiygs of this C my to enter upon the
abov entione o rty for iw
Adction purposes.
20-0026 DPW 4/87
76A667A
CE 817 (REV. 0/86)
APPLICATION FOR PLUMBING7 PERMIT
COUNTY OF LOS ANGELES
DEPT. OF PUBLIC WORKS
Li
FOR APPLICANT TO FILL IN (PRINT
OR TYPE)
ADDRESS 0 �*'l
NUMBER
FIXTURE OR ITEM
@
FEE
LOCALITY
WATER CLOSET (TOILET)
NEAREST
CROSS ST. %V&J >
BATH TUB
SHOWER
OWNER r� i
! l
LAVATORY
MAIL
ADDRESS 0771 / 2 ZEAr—%
SINK
CITY f�TEL. NO. 40
,
DISHWASHER
CONTRACTOR
?•
CLOTHES WASHER
ADDRESS 7_9 %
SWIMMING POOL RECEPTOR
d CITY ! 9� TEL. NO. / �Q
7
%
LAWN SPRINKLER SYSTEM
*�
LICENSE NO. � Q �Q CLASSSTATE LIC, T
DISTRICT NO. PROCESSED BY
v
WATER HEATER
GAS SYSTEM OUTLETS
OUTLETS OVER
5 PIA SYSTEM
VALIDATION Q
DATE FINAL
7
FINAL
BY
W
U) -.
z
;F, O 0 It, 7 A
if 0 0 @ (:
j (;j r
=-
® .j 61 5 l ) ;
tl 7 (018
_...
f R�
Plan check fee
PLUMBING PERMIT ISSUING FEE $
`�
5Z)
TOTAL FEE
16
Plan check applicant
Name
Address
City Tel. No.
13
SEE REVERSE FOR EXPLANATORY LANGUAGE