HomeMy WebLinkAbout0431A (4)- WORKERS' COMPENSATION DECLARATION
APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self
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insure, 'a a certificate of Workers' Compensation Insurance
ICE 817 (REV. 10/81) -
.. or a certified copy thereof (Sec. 3800, Lab. C.
COUNTY OF LOS ANGELES
BUILDING AND SAFETY
Policy No. - Company
Certified copy is hereby turn LShed.
BUILDING
-
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',_ Certified copy is filec{ with the jounty building inspec
FOR APPLICANT TO FILL-IN(PRINT OR TYPE)
ADDRESS
tion department
NUMBER -' FIXTURE OR ITEM- - - (4 FEE
LOCALITY
"
"Date Applicant
WATER CLOSET
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB
CROSS ST.
-
COMPENSATION INSURANCE -
- OWNER
:(This section need not becompletedif the work involved by
SHOWER'
,. the ermit is for one hundred dollars 100 or less.
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LAVATORY
MAIL
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
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SINK -
CITY
TEL. NO.
socis to become subject to the Workers Compensation Laws
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DISHWASHER - -
CONTRACTOR
Date Applicant - " +'-
CLOTHES WASHER
ADDRESS
.' NOTICE TO APPLICANT: If, after making this Certificate of
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Exemption, you should become. subject to . the Workers
- �.vrwsRc..cr ve
CLA -• -
NO.
Compensation provisions of the Labor Code, you must forth
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- LAWN SPRINKLER SYSTEM -
with comply with such provisions or this permit shall be
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STATE -
Lic,TEL
LIC. ,
-, deemed; revoked.
f WATER HEATER - f ..
ILICENSE NO.f
CLASS
LICENSED CONTRACTORS DECLARATION.
.,,.
DISTRICT NO.
PROCESSED BY .
I hereby affirm that I am licensed under provisions of Chapter 9
GAS SYSTFM OUTLETS
I: (commencing with Section 7000) of Division 3 of the Business
OUTLETS OVER -
'- and Professions Code, and my license Is in full force and a ecf.
5 PER SYSTEM -
FINAL
VALIDATION
-
DATE
i
License Number- Lic. Class
FINAL
_
Contractor Date
- -
BY
7-
❑.I am exempt under Sec
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B.BP.C. for this reason-
Plan check fee
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_Date:
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PLUMBING PERMIT ISSUING FEE
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Signature
TOTAL FEE.
,
SINGLE FAMILY
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Plan check applicant
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HOME OWNER-BUILDER DECLARATION
s. I hereby that I from the Contractor's License
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Name
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affirm am exempt
Address
-
Law for the following reason (Section 7031.5, Business and
Professions Code):
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City T.I. No.
QI,I, as owner of the property, will do the work and the
-
structure is not intended or offered for sale (Section
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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.
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Lender's Name`
Lender's Address
S
- I certify that I have read this application and state that the
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above information is correct. I agree to comply with all County
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ordinances and State laws regulating Plumbing, and hereby
-
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authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes.
', SEE REVERSE FOWEXPLANATORY,'LANGUAGE
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I Signature of Permittee' -Date.
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