HomeMy WebLinkAbout2348AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, or
a certified copy thereof (Sec. 3800, Lab. C.)
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Policy No:'' " " Compan�'`�
Certified copy is hereby furnished.
® Certified copy is filed with the county building inspection
,Iepag4rpent.
Date Applicant
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
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date ��� ��� �°pplicant
NOTICE TO APPLICANT: If,�fter making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect.
J,Lcense Number '" Lie. Class
,
Contractor_ Date
D.-I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer
acting. in my professional capacity (Section 7051, Bus-
iness and-Trofessions Code).
Lie. or Reg. No. Date
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions -Code):
® I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project
(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_
i
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.
5 i
Signature of Permrttee Date
CE 817(2-80) APPLICATION F - PLUMBING iT
COUNTY OF LOS ANGELES
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
NUMBER FIXTURE OR ITEM ® FEE
WATER CLOSET
BATH TUB
SHOWER
LAVATORY
SINK
DISHWASHER
CLOTHES WASHER
SWIMMING POOL RECEPTOR
LAWN SPRINKLER SYSTEM
WATER HEATER
GAS SYSTEM OUTLETS
OUTLETS OVER
5 PER SYSTEM
Plan check fee
PLUMBING PERMIT ISSUING FEE $
Plan check applicant
Name
Address
City
TOTAL FEE
Tel. No.
BUILDING AND SAFETY
BUILDING
ADDRESS
LOCALITY
NEAREST
CROSS ST.
OWNER
MAIL
ADDRESS
CITYg i
CONTRACTOR _
ADDRESS
CITY 1
=, STATE
LICENSE NOQI
DISTRICT NO.
FINAL
DATE
FINAL
BY
SEE REVERSE FOR EXPLANATORY LANGUAGE
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TEL. NO.
TEL. NO.`
LIC.
CLASS
PROCESSED BY
VALIDATION