HomeMy WebLinkAbout1520 AUTUMN HILL RD (2)WORKERS' COMPENSATION DECLARATION
APPLICATION FOR
PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self
76A667A
insure, or a certificate of Workers' Compensation Insurance,
CE 617 (REV. 10/811
is or a certified copy thereof (sec. 3800, Lab. c.)
COUNTY OF LOS ANGELES
BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
BUILDING t
ADDRESS
, Certified copy is filed with the county building inspec-
� ❑
tion department.
NUMBER
FIXTURE OR ITEM
C?
FEE
LOCALITY
Date PP1S - A i ant
WATER CLOSET'
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATHTUB
CROSS ST. -
COMPENSATION INSURANCE
OWNER
(This section reed not he completed if the work involved by
SHOWER
the permit is far one hundred dollar* ($100) or less.)
LAVATORY
MAIL
ADDRESS -
-
I certify that in the performance of the work for which this
-
permit is issued,; I shall not employ any parson 1n any manner
SINK
CITY
TEL. NO.
so as to become subject to the Workers' Compensation Laws.
DISHWASHER
-
-
: ,
-
CONTRACTOR
j Dote Applicant -
CLOTHES WASHER
ADDRESS
,.
NOTICE TO APPLICANT: If, .after making this Certificate of
Expmption, you should become subject to the Workers'
SWIMMING POOL RECEPTOR
CITY
TEL. NO. ,
Compensation provisions of the Labor Code, you must forth-
LAWN SPRINKLER SYSTEM
with comply with such provisions. or this permit shall be
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 OUTLETSr
A.'
(commencing with Section 7000) of Division 3 of the Business
OUTLETS OVER
a
and Professions Code, and my license is in full force and effect.
5 PER SYSTEM
FINAL
VALIDATION -
DATE
V
i License Number Lic. Class _
-
FINAL
W
Contractor - Date
BY
a
❑I am exempt under Sec.
< �
_ B.&P.C. for this reason
Plan check fee
Date:
I
PLUMBING PERMIT ISSUING FEE $
W
Signature
TOTAL FEE
-
e e •�*)
Plan check applicant
't
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
Name'J'.e
I hereby affirm that I am exempt from the Contractor's Licenses
Address
..
- Law for the following reason (Section 7031.5, Business and
Professions Code):
City Tel. No.
❑ 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 affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C. ).
_
kemfer'e NanTr ..
t
Lender+* Rrt$r� -
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 lows regulating Plumbing, and hereby
authorize represenrotives of this County to enter upon the
above -mentioned property for inspection purposes. -
' SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permitree Dote
tA ko- 3