HomeMy WebLinkAbout1369A, 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�(SYelc. 3800, Lob. C.)
Policy No. 1 3 C�tojjmpany SAF +2. FDCa
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion deportment.
Date��AppliSant C
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
. (This section need not M completed IF the work Involved by
the permit Is for one hundred dollars ($108) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
n�te Applicant
)ICE TO APPLICANT: If, after making this Certificate of
...mption_ you, should become subject to the .Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing wi$t Section 7000) of Division 3 of the Business
and Professions Code`, and my license is in full force and effect,
License NumberZ\30�a—Lit. Class (I3l[7
Contractor C�e to �(-�-R�
❑ I am exempt under Sec.
B.BP.C. for this reason
Dote:
SINGLE FAMILY
l HOME OWNER -BUILDER DECLARATION
iwhy nffirm that I am wxwmpl from the Contractor's license
Low for the following reason (Section 7031.5, Business and
Professions Code):
❑ f, 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 offirm that there isa construction lending agency for
rhe 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 to enter upon the
above-mentioned property for inspection purposes.
Signature of Permitfere- Date
APPLICATION FOR PLUMBING PERMIT
7BA887A
CE 817 (FEV. 8/88) - -
COUNTY OF LOS ANGELES
Plan check fee
PLUMBING PERMIT ISSUING FEE $ -
TOTAL FEE
Pion check applicant
Name
Address
City., Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
DEPT: OF PUBLIC' V
ADDRESS Inal
CITY TEL. 1,10 6:31
STATE ^� s n ./'s n UC. /s _
mason
FINAL VALIDATION
DATE
FINAL �
BY ,S/6,
101
:-1 369A
A•••..5
f=•7650
•a•7b5n�
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
ABER
FIXTURE OR ITEM ®
FEE
WATER CLOSET - -
f
BATH TUB
SHOWER
LAVATORY
'
SINK
I
DISHWASHER
CLOTHES WASHER
SWIMMING POOL RECEPTOR
LAWN SPRINKLER SYSTEM
WATER HEATER
J
GAS SYSTEM OUTLETS
/ r
Plan check fee
PLUMBING PERMIT ISSUING FEE $ -
TOTAL FEE
Pion check applicant
Name
Address
City., Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
DEPT: OF PUBLIC' V
ADDRESS Inal
CITY TEL. 1,10 6:31
STATE ^� s n ./'s n UC. /s _
mason
FINAL VALIDATION
DATE
FINAL �
BY ,S/6,
101
:-1 369A
A•••..5
f=•7650
•a•7b5n�
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