HomeMy WebLinkAbout4419A (20)WORKERS' COMPENSATION DECLARATION
I hereby, affirm that 1 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 NoA±— j _4Company ge'1! j3a I e %N l-)
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection
department.
Date '" "<5 Applicant � �� ''- I
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
-ICE TO APPLICANT: If, after making this Certificate of Ex-
tion, 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 Lic. Class
Contractor Date.
I am exempt under Sec.
B.&P.C. for this reason
Date:
Signature
20-0026 DPW 4/87 APPLICATION I
76A667A
CE 817 (REV. 8/86) i
COUNTY OF LOS ANGELES
FOR APPLICANT TO FILL IN (PRINT
OR TYPE)
BUILDING
ADDRESS 7° e
NUMBER
FIXTURE OR ITEM
@
FEE
LOCALITY
WATER CLOSET (TOILET)
NEAREST
CROSS ST.
BATH TUB
OWNER s
/7'4 j
SHOWER
LAVATORY
MAIL _
ADDRESS . :�4e%
SINK
CITY L9 -/e _1J'�r , .a TEL. NO,_7
DISHWASHER
CONTRACTOR4
CLOTHES WASHER
ADDRESS
SWIMMING POOL RECEPTOR
CITY TEL. NO.
LAWN SPRINKLER SYSTEM
_
STATE LIC.
LICENSE NO. CLASS
DISTRICT NO. PRO&1EP Y
,\ti
`
WATER HEATER
GAS SYSTEM OUTLETS
OUTLETS OVER
5 PER SYSTEM
FINAL
DATE
FINAL
BY
VALIDATION
Plan check fee
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
Plan check applicant
I hereby affirm that I am exempt from the Contractor's License
Name
I `or the following reason (Section 7031.5, Business and
F. ;ssions Code):
Address
I, as owner of the property, will do the work and the
City
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 Coun y to enter upon the
above- rno er8 prop e ty fo�specut2tlpurposes.
i
MA1_
gnpt re of Permittee Date
Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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