HomeMy WebLinkAbout1598AWORKERS' 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 tbt countytbuilding inspection
�lepart�n ) ,,
Dat 11., Applicant—C �
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 �✓�'`� Lie. Class
Contractor A� Date 2d - E e C'-?
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).
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
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- �ntioned prmpyeor inspection purposes
f.
Signature of Permittee Date
CE 817 (2-80) APPLICATION PLUMBING
COUNTY OF LOS ANGELES
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
NUMBER FIXTURE OR ITEM FEE
WATER CLOSET
BATH TUB
SHOWER
LAVATORY
SINI<
DISHWASHER
CLOTHES WASHER
SWIMMING POOL RECEPTOR
LAWN SPRINKLER SYSTEM
WATER HEATER
GAS SYSTEM OUTLETS
5 PER SYSTEM
BUILDING AND SAFETY
BULDING
ADIDRESS , �'Y f r �a
LOCALITY ,.
NEAREST
CROSS ST.
OWNER
MAIL
ADDRESS V
CITY TEL. NO
CONTRACTOR
ADDRESS 4'
CITY — TEL. NO.)�.'�/.
0 STATE ✓ LIC. % f
LICENSE NO. ��'� CLASS `J/
DISTRICT NO. PRObESSED BY
FINADATE /Iz`i;�R/IPa? VALIDATION
Plan check fee
PLUMBING PERMIT ISSUING FEE $ 611 (11
TOTAL FEE J�C "C�f
Plan check applicant
Name
Address
City Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
FINAL
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