HomeMy WebLinkAbout7038AWORKERS' 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.)
Policy No. Company
® Certified copy is hereby furnished.
Certified copy is filed with the county building inspection
epartment.
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 Applicant
NOTICE TO APPLICANT: If, after 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 revolted.
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.
License Number Lic. Class
Contractor Date
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 Professions Code).
Lic, 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):
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
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 resentatives of this County to enter upon the
above_p, 'one r e f inspection purposes.
Signature of Per tttee Date
CE 817 (2-80) APPLICATION IT
COUNTY OF LOS ANGE LES
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 $
TOTAL FEE
Plan check applicant
Name
Address
City/dI ir'9t` Tel. No. C�lI�71��i
SEE REVERSE FOR EXPLANATORY LANGUAGE
BUILDING AND SAFETY
BUILDING
ADDRESS��
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OWNER
MAIL
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CONTRACTOR
ADDRESS
CITY
TEL. NO.
STATE
LICENSE NO.
DISTRIC NO.
LIC.
CLASS
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