HomeMy WebLinkAbout6569WORKERS' 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. C.)
Policy No,�%7-151�'w'Y,7Company �S]� 5g"n7 /
Certified copy is hereby furnished.
i L I Certified copy is filed with the county building inspection
�! deportment,
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 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 -
Ilion, 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
Cal
Contractor ,f %ci�... C9�ra�g VZ e
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
for the following reason (Section 7031.5, Business and
I, fissions 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 Code).
CONSTRUCTION LENDING AGENCY
I hereby off€rm 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 proppdj5W inspection purposes.
26-W26 DPW 4/87
76A667A
CE 817 (REV. 9/86)
COUNTY OF LOS ANGELES
FOR APPLICANT TO RLL IN (PRINT OR TYPE)
NUMBER FIXTURE OR ITEM @
WATER CLOSET (TOILET)
BATH TUB
SHOWER
LAVATORY
SINK
DISHWASHER
CLOTHES WASHER
SWIMMING POOL RECEPTOR
LAWN SPRINKLER SYSTEM
WATER HEATER
GAS SYSTEM OUTLETS
OUTLETS OVER
Plan check fee
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
Plan check applicant
Name
Address
city Tel. No.
FEE
DEPT. OF PUBLIC WORKS
BUILDING
ADDRESS
LOCALITY
NEAREST
CROSS ST.
OWNER
MAIL
ADDRESS
CITY
CONTRACTOR �^
/�
ADDRESS
CITY
STATE
LICENSE NO.
0t5TRICT NO.
to
FINAL
DATE
FINAL
BY
I
11
0
TEL. Nl ?SC A , ],C f
TEL. N
J r5
LIC.
CLASS
PROCESSED BY
ALIDATION
6�
Z
iJ
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Dote