HomeMy WebLinkAbout1638 KIOWA CREST (2)WORKERS' COMPENSATION DECLARATION
APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self
75A667q
insure, or a certificate of Workers' Compensation Insurance,
CE 817 (REV. 10/81)
or o certifj4acopy thereof (Sec. 3800, b. CQj
. COUNTY OF LOS ANGELES
BUILDING AND SAFETY
Policy10—Y1212Y-1 Compony^�-
Certified copy is hereby furnishei
�Cerlified co y is filed with the coup building inspec-
tion depa ant.
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
BUILDING
T
G sa
NUMBER
FIXTURE OR ITEM
®
FEE
LOCALITY
pate 2 Applicant
WATER CLOSET
NEAREST
CER FICATE OF EXEMPTIOffGM W RKERS'
BATH TUB
CROSS ST.
COMPENSATION INSURANCE
OWNER
(This section need not be completed If the work Involved by
SHOWER
the permit is for one hundred dollars (f100) or loss.) I
LAVATORY
halt
ADDRESS
Icertify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
SINK
CITY TEL.
so as to become subject to the Workers' Compensation Laws.
DISHWASHER
CONTRACTOR
Date Applicant -
CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should became subject to the Workers'
SWIMMING POOL RECEPTOR
CRY
Compensation provisions of the Labor Coda, you must forth-
LAWN SPRINKLER SYSTEM
r
with comply with such provisions or this permit shall be
STATE LIC.
deemed revoked.
WATER HEATER
LICENSE NO. Z--- cLA
LICENSED CONTRACTORS DECLARATION
DISTRICTF/1Q
I hereby affirm that I am licensed under provisions of Chapter 9
C'Ar STEM OUTLET a
(commencing with Section 70M) of Division 3 of the Business
C
OUTLETS OVER
and Professions Code, and my license is in full farce and effect.
5 PER SYSTEM FINAL 1
DATE
License Number l 7 Z—L ic. Class
Z6 I 6;T
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6
FINAL j
8Y
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Contractor ' � ` Date
('
❑ 1 am exempt under Sec.
BAP.C. for this reason
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE E D S
Signature
TOTAL FEE
Pion check applicant -
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
- Name
I hereby affirm that I am exempt from the Conlractor's License
Address
Low 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.).
Lender's Name
Lender's Address
I certify that I hove read this application and state that the
above informoli r correct. I agree to comply with all County
.
ordinances ord to lows regulating Plumbing, and hereby
authorize repr ntatives of this County to onto upo the
above•me io property for inspection purp 6.
/
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig a of Perm ee Date'
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