HomeMy WebLinkAbout1403AWORKERSm. COMPENSATION DECLARATION
.__
a
FOR PLUMBING�iMIT
! hereby affirm that f have o certificate of consenr to self
APPLICATION
`73 y3p
insure, or a certificate of Workers' Compensation Insurance,
CE 477 (REV. 10/81)
or a ca;rifte'd copy thereoff IS . 3800,,, Laub. C. )�
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Pali o �-Z1 1 Z,`onipany [ +%O S - Ill-SU
Certified is hereby furnished. a
copy
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
BUILDING t ll
ADDRESS �3 N
>-
❑-
Certified copy is filed with the c
}ion department.
'�%��
ui i g inspec-
NUMBER
FIXTURE OR ITEM
(@
FEE
LOCALITY 1� fi. s
1
��'•�} ����
Dole) Applicam
WATER CLOSET
NEAREST -
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB -
CROSS ST.
COMPENSATION INSURANCE
OWNER r
(This section need not be completed IF the ork Involved by
w
SHOWER
ln�rI`Kp
the permit Is for one hundred dollars ($100) or less.)
LAVATORY
MAIL tt 9p
ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
SINK
C111
MO TEL NO.
so as to become subject to the. Workers' Compensation Laws.
DISHWASHER
COMRACTO
Date Applicant - - -
CLOTHES WASHER
ADDRESS-
-
NOTICE TO APPUCANR If, after making this Cert4imte of
t
- Exemption; you should become subject to the Workers'
SWIMMING POOL RECEPTOR
CI TEL. fJO.
/�
Compensation provisions of the Labor Code, you must forth-
LAWN SPRINKLER SYSTEM
O r
with comply with such provisions or this permit shall be
STATE LIC.
deemed revoked.
WATER HEATER
LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION_ ... ..
r
DISTRICT . PfOgSSED BY
I hereby affirm that I am licensed underprovisions of Chapter 9
GAS SYSTEM OUTLETS
10
(commencing with Section 7000) of Division 3 of the Business
OUTUJS OVER
-�J�'•
and Professions Code, and my license is in full force and effect.
5 PER SYSTEM
FINA Xr'`
VALIDATION
License Numbe Lic Class_.,
DATE�r/7 O J
Conh6o�41,11'rTatE /�%r FINA 0
BY - Q
❑w
I am exempt under S.C. a.
BAP.C. for this reason _
--_ Plan check fee
PLUMBING PERMIT ISSUING FEE $ S _
Signature ...
. . , . .. .... TOTAL
Plan check rsnpliront
-- SINGLE FAMILY
i HOME OWNER -BUILDER DECLARATION
Name
t hereby affirm that I am exempt from the Contractors License
Address
Law for the following reason (Section 7031.5, Business and
_ Professions Code):
City
❑
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 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
Lenders Address
I certify that I hove read this application and state that the
i rmation is correct. I agree to comply with all County
and SlLp(�re law egu1 ling Plumbing, and hereby
2rdiric
ize pr eArotivs f this County to enter upon the
io d pr at for inspection purposes.
Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee ", Data
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Iee3050
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07.17-85
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