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WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT - - - - I hereby affirm that i have a certificate . of consent to self 75g667A
insure, or a certificateofWorkers' Compensation Insurance, ,-- CE.8t7.(REV. I0/8I)
or a certified copy thereof (Sec, 380D Lob.. C:)
Policy No. Company_
COUNTY OF LOS ANGELES BUILDING AND SAFETY
n ified copy is hereby furnished.
O'//
Certified copy is filedwiththe county building inspec-
FOR APPLICANT TO FILL IN (PRINT OR TYPE) ButIDIN" ADDRESS
tion department. - NUMBER FIXTURE OR ITEM - FEE
LOCALITY
Date 7 - rAp tTcwiaf .tirLL k -IV WATER CLOSET _ _ ---_ ter
NEAREST 1 ., 1L) A CjCERTIFICATEOFEXEMPTION-fROM WORKERS'- - BATH TUB CROSS ST. 7 f f v
V1
Yc (z -
COMPENSATION INSURANCE
SHOWER - - - OWNER tJ E T vThissecttinneedmothecompletediftheworkholved- by
the perm t is formai hundred dollars ($M) V, less) LAVATORY ADDRESS I or) L. (. VAlIcertifythat -in the -performance--<rf-the-work-#oe-which this
permit_ is issued, I shall not employ any person in any manner SINK- - - CITY - TEL NO.
so as to become subject totheWorkers'-Compensation Laws.
DISHWASHER CONTRACTOR -
pate 2c-iwTmm LFl
CE ADDRESSTOAPPLICANTIf, after making this Certificate of
ptEon you s roufd t4 rs' SWIMMING POOL RECEPTORbeconr .sgbj-e.4.f _::YiQCk
or this youit shall rbCompensationprav'euchcomply LAWN SPRINKLER SYSTEMwithwithsuchprovisionsorthispermitshallberoviisions STATE T
deemed revoked: - - - - - :-.. - WATER HEATER - r LICENSE NO. - CLASS -
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
1 hereby affirm that_ f am licensed under provisions of Chapter 4 GAS SYSTEM OUTLETS
commencing with Section'7MD) of Division 3 of the Business OUTLETS OVER
and Profewons Code, ondmy.license is infill force-andeffect. 5 PEP, SYSTEM FfNAC -- VALIATION
h /_' n-l DAT
License Number I ic. close 6
Contractor i Qld/A 4 '_ BYMDate a
1 am exempt under -Soc ... - - u
B.BP.C. for this reason
Plan check fee 2
Date:
PLUMBING PERMIT ISSUING FEE E t r( Signature 21 2 2. L A
TOTAL FEE_ LCO
4
Plan check applicant - -
SINGLE FAMILY I • 1 Q C) HOME OWNER -BUILDER DECLARATION Name
by affirm that t am exempt from the Contractgr's,license ..-,. Adrfrsss :,: - ._ ..,,;._,,,,...__;,.;_
r =
iv- .
Et_ forthe #oftawjrrg'reasoa (SeciFan-3(f3T.5; Business and' T— -
Professions Code): - Cily -- - Tel. No. 0 %. C:9.-"8 v - - D1, as owner of the property, will do the work and the-
structure is not intended or offered for safe (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 far which this, permit is issued-
Sec: 3097, Civ. C.).
Lender's Nome
Lender's Address
I certify.that I havereadthis application and state that the
above informotton is correct:, t agreeto comply with all County -
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the -.
above-rrtuned property f nspectian purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sigl at of Permittee - Date
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