HomeMy WebLinkAbout0WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 768 7( 14�y
insure, or a certificate of Workers' Compensation Insurance, CE 811 7 (REV. )0/81)
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES
Policy No. _ Company
Plan check fee
BUILDING
AND SAFETY
rlCertified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
BUILDING
-
❑ Certified copy is filed with the county building inspec-
tion department. _.
NUMBER FIXTURE OR ITEM FEE
ADDRESS
LOCALITY
Date Applicant -'
WATER CLOSET
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS''
BATH TUB
CROSS ST.
I COMPENSATION INSURANCE
.-,
(This section need not be completed If the work Involved by
SHOWER
-
.OWNER
'
the permit Is for one hundred dollars ($100) or less.)
LAVATORY
MAIL
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I certify that in the performance of the work for which this
Address
ADDRESS
-
permit is issued, I shall not employ any person in any manner
SINK
CITY
TEL. NO.
so as to become subject to the Workers' Compensation Laws.
-
DISHWASHER
CONTRACTOR
Date Applicont
CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of
ADDRESS
Exemption, you should become subject to the Workers'
SWIMMING POOL RECEPTOR
�
Compensation provisions of the Labor Code, you must forth-
CITY
TEL NO:
with comply with such provisions or this permit shall be
LAWN SPRINKLER SYSTEM
STATE
LIC,
deemed revoked.
' WATER HEATER
LICENSE NO.
CLASS
LICENSED CONTRACTORS DECLARATION
"..
DISTRICT NO,
PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9
GAS SYSTEM OUTLETS
ordinances and State laws regulating Plumbing, and hereby
" (commencing with Section 7000) of Division 3 of the Business
OUTLETS OVER
authorize representatives of this County to enter upon the
- and Professions Code, and my license is in full force and effect.
5 PER SYSTEM
FINAL _
VALIDATION
License Number Lic. Class
SEE REVERSE POR EXPLANATORY LANGUAGE
DATE
Signature of Permittee. out.
'
FINAL
Contractor Date
BY
❑ I am exempt under Sec.
-,
B 8P C for this reason
F
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE $
Signature
•
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
Name
'
I hereby affirm that I am exempt from the Contractor's License
i ♦ �,a�, a:
Law for the following reason (Section 7031.5, Business and
Professions Code):
Address
•, •.,"
City Tal, No.
❑ I, as owner of the property, will do the work and the
for
structure is not intended or offered sale (Section
pot
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
(set. 3W7, Civ. G.).
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Mmibrrs 190y"
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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.
SEE REVERSE POR EXPLANATORY LANGUAGE
Signature of Permittee. out.
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