HomeMy WebLinkAbout1036AWORKERS'COMPENSATION DECLARATION
I hereby affirm that I have acertificate of consent to self
Insure, or a certificate of Workers' Compensation Insurance, or
;I a certified copy thereof (Sec. 380Q Lal `
Policy NoiMy Company
Certified copy is hereby furnished.
r,Certified copy is filed with the county budding inspection
department.
�r 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.)
y I certify that in the performance of the work for which this
,. permit is issued• 1 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
I 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
1 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
i effect.���
License Numbeerr/3edZdS��//��� Lia Class
Contractor Date
Date
I 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. No. Date
HOME 05VNER-BUILDER DECLARATION
f1 hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5. Busi-
ness and Professions Code):
ElI, as owner of the property, am exclusively contracting
with licensedcontractors to construct the project
(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 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 q enter upon the
aboveoned prop ty c ' poses.
27e
2 A/
Signature of Pe i t Date
C4KWAJr-4101 APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES ' BUILDING AND SAFETY
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
:R FIXTURE OR ITEM FEE
WATER CLOSET
BATH TUB
SHOWER
LAVATORY
SINK
DISHWASHER
CLOTHES WASHER
SWIMMING POOL RECEPTOR
LAWN SPRINKLER SYSTEM
WATER HEATER
GAS SYSTEM ;OUTLETS
Plan check fee
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
Plan check applicant
Nam.
Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
BUILDING
ADDRESS
LOCALITY
OWNER ,
CITY TEL. NO.
CONTRACTOR OIL-
ADDRESS
lO/� �.,�
CITY Sy ::! Frn .STATE.%•�S� TEL. NO. +
LIC
LICENSE NO. 3S"Z)_-9V CLASS CS—
DISTRICT NO. Pq CESSED BY
/O
FINAL
DATE �a,.-/7-�� VALIDATION
FINALBY
:11036A
#• +5
I••1Z50
•125.05
1216;8,1
ill
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O
U
APPROVALS DATE INSPECTORS SIGNATURE
UNDER SLAB WORK
ROUGH PLUMBING
GAS PIPING' -
GA5 VENT
HO WATER HEATER
PLUMBING FIXTURES - - -
GAS TEST
UTILITY CO. }�
NOTVFIErnD �� ry.n- -
FINAL _ - C#d i p. 4,ow
INDUSTRIAL
WASTE. APPROVAL -
INSPt(:I vWb INU 1 LD OWNL• K-bUILOLK ULL'LAKA J JUN
- 1 hereby, affirm thal I am exempt from the Contractor's
License Law forl'the'following reason (Section 7031.5, r
' Business and Professions Code): An)' city or county
which requires a permit to construct. alter, improve,
demolish, or repair any structure, prior to its issuance,
also requires the applicant for such permit to file a'
signed statement that he is licensed pursuant to the
provisions of tire Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the
.. - Business and Professions Code) or that he is exempt
therefroin and the basis for the alleged exemption. Any
- - - violation of Section 7031.5 by any applieant fora permit
subjects tire applicant to a civil penalty of trot more than
five hundred dollars ($500).:
❑ L as owner of the property will do the work, and
the structure is not intended or offered for sale.
(Sec. 7043, Business and Professions Code: The Corr-
-- tractor} License Law does not apply to air'oroner of
property, aeho builds or improves thereon, and schp does
h - - - such work hinself provided that such improvements
..
are trot intended or offered for sale. If, however, the
- building or improvement is sold within one year of
�\ completion, the owner -builder will have the burden
of proving that he did trot build or improve for the
Purpose of sale.)
I am exempt under Sec.
B & P.C. for this reason
Date
Owner
,azo r
• • • INSPECTOR'S NOTES
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