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HomeMy WebLinkAbout1208AWORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers' Compensation Insurance, CE 817 (REV. 10/81} or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company Certified copy is hereby furnished. APPLICATION FOR PLUMBING PERMIT t ' COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspec- tion department. Date /L _q —f'f ApplicantJJ r'• �`� FOR APPLICANT TO FILL IN (PRINT OR TYPE) NUMBER FIXTURE OR ITEM WATER CLOSET BATH TU8 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER (This section need not be completed If the work Involved by LAVATORY the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which thil permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. SINK DISHWASHER Date Applicant CLOTHES WASHER 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 SWIMMING POOL RECEPTOR LAWN SPRINKLER SYSTEM WATER HEATER deemed revoked. LICENSED CONTRACTORS DECLARATION ` V GAS SYSTEM OUTLETS I h b ffirm that ! am licensed riderovisions of Cho ter 9 ere y a u p p (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and effect. 5 PER SYSTEM, License Number Lic. Class Contractor Date I am exempt under Sec. BAP.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE $ Signature TOTAL FEE ADDRESS J 67 LQ t FEE LOCALITY (V,rjL it1y NEAREST CROSS ST.--AZLFI A�-60 OWNERAAAIL ADDRESS IJ 3 C' E IsLt CITY bV ht Iva r CITY FINAL DATE FINAL BY TEL. NO, Llc. CLASS t PROCESSED BY [ ►fALIDATIOW ` O 3' fid I 0 u a`L il in SINGLE FAMILY HOME OWNER -BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. - ® _ 1, 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 r• "'i :: � 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 Addres3-,J . �i- 6 s'. - 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 outhorizi�j representatives of this County to enter upon the e pp rly for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 4abo,mi of Perm ne r Date » 0 § z r) k =£&&7e�;=z-0 � •� -m u a07:;\/{2f\ƒ \ƒ�§�\\ ,ego,—13}a©k 0))j§7»;]} I/,&§0Ke.�§� ®-0 EL0 §0 C, «a;�! ' tj=r-®$-;%s�I /-f°-cc ea%Q.\ U 0 fL % »] %~{& ��r2!K©�| /}k�kE «r— %2 —C/« » .5«{#zzz%e o- [§ƒ Ewa\O.M §s-_m2 e/a§&% ,,'2�.��$e�■f!!- �=\\ascc.r46.-ao!-0. .0o 04) »§�2fXo %s-ZL §�!§22|0k■- .=| 42wo§!2I§g-§�g,%2-!fi),]ik)ID r@ t o 7kƒf{b }■)k��?k)�J22§�at�}2e�± \ CI- 3 kj\\ ��§ti$/`� ei}$%7|� Eu�� eG £� 3».to2 \ § k ■ 2 � k § .� / E _Z A \ n T (2 § ° �( I k § / 2 / 7 k\ 2 ! \ ƒ 3 � /