HomeMy WebLinkAboutNo Permit Number (39)WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, or
a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection
department.
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed if the work involved
by the permit is for one hundred dollars ($100) or less.)
1 certify that in the performance of the work for which this
permit is issued, i shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
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
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and professions Code, and my license is in full force and
effect.
License Number Lic. Class
Contractor. Date
am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code).
Lic. or Reg. IN Date
HOME OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code):
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project
Section 7044, Business and Professions Code).
GammememLallome eta
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
Issued (Sao. 3097, Civ. C.),
LendeYs Marne
LerdvrS AVditn
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
abov tinned pro t for i//nspection purposes.
Si fur f Permittee Date
CE817(Z-cal APPLICATION FOR PLUMBING PERM
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FI LL IN (PRINT OR TYPE)
cR FIXTURE OR ITEM FEE
WATER CLOSET
BATH TUB
SHOWER
BUILDING
ADDRESS IZ
LOCALITY L
NEAREST
CROSS ST.
OWNER
MAILADDRESSLAVATORY A
SINK CITY
DISHWASHER CONTRACTOR
CLOTHES WASHER ADDRESS
SWIMMING POOL RECEPTOR
CITY
LAWN SPRINKLER SYSTEM STATE
WATER HEATER LICENSE NO.
DISTRICT NO.
GAS SYSTEM OUTLETS
OUTLETS OVER
5 PER SYSTEM
FINAL
CQDATE -' S V
FINAL
BY
Plan check fee
PLUMBING PERMIT ISSUING FEE $ Sfj
TOTAL FEE -2 2
Plan check applicant
IL
Addle"
City T.I. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE.
TEL. NO,
TEL. NO.
LIC.
CLASS
PROCESSED BY
VALIDATION
r c
e:
9.
APPROVALS DATE INSPECTORS SIGNATURE
INS..^ECTOR'S NOTES
UNDER SLAB WORK
ROUGH PLUMBING
GAS PIPING -
GAS VENT
HOT WATER HEATER
UMWNG FIXTURES
GAS TEST
UTILITY CO. NOTIFIED
FINAL
V40 fETRIAL
Afi E AFP ROYAL
INSPECTOR'S NOTES
DLCLAKATID
I r.: x:by Wfii-"j tlr:t 1 r. ,.n nxempt fmnn the Contrictor's
L; -y- 1 1.r.v- for the fo':lsiciwa reason (Section 7031.3,
rr:d Frcfessivne Co :'c J: Any city or county•
x•Gach "%"'ui'eT a P"ndt to consrru'l' alter, improve,
der.:e?ck, or rrpc, r m.:y smcruoe. Prior to its issues:.^e,
ale- rec;lr5r; the an, rtirwu fcr .such permit to file a
V."! I tl:rr he is lice.'tced pursarmrt to the
p;oriritva of rltc Con.traetor's License Law (Chapter 9
ncrs,•r:ria-N x'itf, Srcti-. 7000) of Division 3 of the
Er.,cia: rsc a^: ;' FS'ofzs^son.,; Cody or that he is exempt
tA:=mflonr a+:r° the bra's for.thz a!legcd exemption. Any
viaLsiw: a`S,wicn 7031.5 byaayapp!icaattfoea perttdt
s:tE i it th, r:',r: 'Cent to a civil pcn:hjv of nor rrmre than
f.*;,,i:.rn,'h,e:!do'lrks(S50 ).:
1, as owr._-r of 0+ property x01 do the work, and
8._ srmcturz is not ictun].:d or offered for side.
0`e- 70,", Eus!u:'ss w:J Frofezdnns Code: The Con -
Lk, -;r_ Laty do.,.r not apyty to arc owner of
7y -':0 bt'.i!47 nr ir, ;;,•ores (I—Cor., 6,,W who doe,
w'h won"c provi:'.:' rl:ct s;ch imr overaents
ar:• ro.` iet. r±t.'ct.' or for s::le. If, however, the
b::i_L=r• or b::,^rc rerrsut L: so!^ x-itl:ix o:re near of
owrr.'rrb:,•i:'der will have the burden
of T,o^ic" t1;ru he did not baeild or ingmove for the
g, t 4.(. for Ws remon
D:J,
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