HomeMy WebLinkAbout4582AWORKERS' 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. �Cww. )
S� Policy No.ff 3J �'�2 �ompany CAt/6-
❑ Certified copy is hereby furnished.
Certified copy is filed with the countvibuilding insp ction
department.
Date_ 5 Applicants
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
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, 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 Si!4Sv
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
Law for the following reason (Section 7031.5, Business and
Professions 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 Cade).
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.
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
NUMBER
FIXTURE OR ITEM
@
FEE
LOCALITY
�� �� - -�//�Y6iC✓�l�
WATER CLOSET (TOILET)
NEAREST �/�
CROSS ST. � &jr11 d �J
BATH TUB
SHOWER
OWNER
LAVATORY
MAIL
ADDRESS
SINK
CITY TEL. NO.
DISHWASHER
CONTRACTOR
d�
CLOTHES WASHER
ADDRESS , J Y f
SWIMMING POOL RECEPTOR
CITY /1/ �r� ` a „y TEL NO. jet
7 ! 1 v
LAWN SPRINKLER SYSTEM
/
rG1
t
j
STATE
2 6 LIC.
LICENSE NO. Cj > " i r CLASS
WATER HEATER
GAS SYSTEM OUTLETS
DISTRICT NO.
/0
PROCESSED BY
2
OUTLETS OVER
5 PER SYSTEM
FINAL f
DATE_ ')
VA IDATION
BY
Plan check fee
PLUMBING PERMIT ISSUING FEE $ 0
TOTAL FEE G�
Plan check applicant
Name )
Address
City Tel. No.
C
0
Z
Signature of Permittee Date
SEE REVERSE FOR EXPLANATORY LANGUAGE