HomeMy WebLinkAbout1103A (5)WORKERS' COMPENSATION DECLARATION
APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a cerlificofe of consent to self
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insure, or a certificate of Workers' Compensation Insurance,
CE 817 (REV. 6/88)
co Sec. 3800, Lab. .)
' or a certifiedthen C
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P❑N� ompany U ` �l`�f\CL
olicy
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COUNTY OF LOS ANGELES
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Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
BULLRING �l �,r ,yam
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Certified copy is filed with the county building inspec•
ADDRESS
deparLmant.
NUMBER
FIXTURE OR ITEM FEE
LOCALITY /LC{
Ation
Q(� .P
WATER CLOSET Op
D Appli;ant
CERTIFICATE OF EXEMPTION FROM WORKERS'
p�
BATH TUB
NEAREST -
=SIT. M
COMPENSATION INSURANCE
-
OWNER
'This section need not be complefed if the work Involved by
SHOWER
-
-
the pennB Is for one hundred dollars (11100) or less.)
LAVATORY 'a
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
SINK jCpCITY
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26-7
so os to become subject to the Workers' Compensolion Laws.
DISHWASHER -
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CONTRACTOR F�l7 C
Date Arpliconl
AS- �Q
CLOTHES WASHER/C00/
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ADORE55 / C O Ut
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NOTICE TO APPLICANT: If, after making this Certificate of
,Exemption, you should become subject to the Workers'
,ppensolion
SWIMMING POOL RECEPTOR
CITY
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1 provisions of the Labor Code, you must forth-
IAWN SPRINKLER SYSTEM
..h comply with such provisions or this permit shall be
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deemed revoked., - -
WATER HEATER
OD
LICENSE NO. ..] O CLASS L-% W
LICENSED CONTRACTORS DECLARATION
DISTRICT NO. PROCESSED BY
I m hereby affirthat I am licensed under provisions of Chapter 9
GAS SYSTEM OUTLETS p
1
�Q O
(commencing with Section 7000) of Division 3 of the Business
OUTLETS OVER
0
and effect.
and Professions Code, and my license Is in full forceL
5 PER SYSTEM
FINAL
VALIDATION
(v�-
3t a�� lit. Class '� � W
DATE 4 3 0/r.� (]
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V
0:
License Number
FINAL
•Dat
Contractor \— e.
BY U/%` •�j�"�j
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❑ I am exempt under Sec.
W
a
N
B.BP.C. for this reason
Plan Check fee -
Z
Date.
PLUMBING PERMIT ISSUING FEE $ 1 Q St)
' Signature
TOTAL FEE
- - -
Plan check applicant
1 1 11 3 A
SINGLE FAMILY
..
HOME OWNER-BUILDER DECLARATION
Name
- - - a • • • s 5
I hereby offirm that I am exempt from the Contractor's License
- Address
r', for .the following reason (section 7031,5, Business and
( ° 1 06.50
,essions Code):
Cit Y
Tel. No.
❑ 1, as owner of the property, will do the work and the
W Y,
structure is not intended or offered for sole (Section
ed
-
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► - - � - - 0827-87 - -
7W1, 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 1 have read this application and state that the
-►
- - -
above Information Is correct. I agree to comply with all County
ordinances and State lows regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
-
-
obove•memioned properly for inspection purposes.
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SEE REVERSE FOR EXPLANATORY LANGUAGE
::;% R?
gn ure of PerDate
1.
AFPROVAS
UNDER StAB
POUCH Fa"AFING—
GAS P[P.NQ',
,'S SIGNATU2t
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GAS VENT
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pe—i.y tofir—'vqn�ej
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for's L.,v ?�es r.toppFy'f. fpr�
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work hl 'sell provided thof such Imp —oments.- ""i
ir,fond,d o.Ffo,ndl 'far af, J, ho,e,-,r. the 1, ildmg o,
f imp'o'emert is cold "Uhm ."o ye of the
ho— the burden .f proving thmth- 1,d
not build or Improve for the purpose Df sol,
a, exempt Una -
6r, Ulis,, ason
INSPECTOR'S NOTES -- -------
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INSPECTOR'S 1407ES
hco-, to, 1- 11,, 4.!l —,-7 u., 'S.Mv, 702J 5.
Busi_, o"d P'n fo—o- Code� AIy cHyo
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pe—i.y tofir—'vqn�ej
2; P"—'—s of the
Lorl"rclor5 if,cnse
5ecti— 7000)'of Dwisl— 3 of the Cu,ln-s end Prefo,
e is c�Z-Ap the be,,,
Color or that f- t1h
for lire` t,
lten, 'I. '.f 'S--
ep."e
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6 —d jerofiy of not ,noru
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of th,, r .Fntl —h cl,,.,k, —d
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for's L.,v ?�es r.toppFy'f. fpr�
h buil'A .r !n--prj— tfi,r..n. 6,d h,, d.o, h
work hl 'sell provided thof such Imp —oments.- ""i
ir,fond,d o.Ffo,ndl 'far af, J, ho,e,-,r. the 1, ildmg o,
f imp'o'emert is cold "Uhm ."o ye of the
ho— the burden .f proving thmth- 1,d
not build or Improve for the purpose Df sol,
a, exempt Una -
6r, Ulis,, ason
INSPECTOR'S NOTES -- -------
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