HomeMy WebLinkAbout1509A (8)WORKERS' COMPENSATION DECLARATION
APPLICATION FOR
PLUMBING
PERMIT
I hereby dltjrm that I have a certificate of consent to self
20-0026 DPW 6/87
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insure, or u certificate of Workers' Compensation Insurance,
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or certified copy thereof (Sec. 3800, Lob. C.)
COUNTY OF LOS ANGELESDEPT.
OF
'.--.
PUBLIC WORKS
No.
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/j F- 3 f
Policy Company
Certified copy is hereby furnished.
City O T.I. N-.7yy 6t/
,�
I -22500
❑FOR
Certified copy is filed with the county building inspect
APPLICANT TO FILL IN (PRINT OR TYPE)
BUILDING
ADDRESS Ep J
AW� 3C -F
L
tion department.
NUMBER FIXTURE OR ITEM FEE
LOCALITY�r
_
• ° e 2 2.5 0
�
Date Appli4ont
WATER CLOSET
+
ST.
d �/
CERTIFICATE OF EXEMPTION FROM WORKERS' -
BATH TUB -
CROSS 0
9 T 2 - 8
COMPENSATION INSURANCEffL—
5HOWER
(This section need not be completed If the work Involved by
1
r Til All
the permit is for one hundred dollars ($I00) or less.)
LAVATORY
MAIL ESS
ADDR
AS-
1 certify that in the performance of the work for which this
-
permit is issued, I sholl not employ any person In any manner
SINK - -
CITY
TEL NO.
so as to become subject to the W pws.
-
-
D
Data�� Q` C
Data O o Applicant -
DISHWASHER
CLOTHES WASHER
CONTRACTOR
lv`o t_
above information is correct. I agree to comply with all County
- -
ADDRESS
NOTICE TO APPLICANT: -If, after making this Certificate of
Exemption ou should become sub-ect to the Workers'
SWIMMING POOL RECEPTOR
• Y 1
Compensation provisions of the labor Code, you must forth- CITYTEL. NO.
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM '
deemed revoked. - WATER HEATER - LNCLIC.
SE NO
LICENSED CONTRACTORS DECLARATION DISTRICT NO.SSED 8Y
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS M ^ n
(commencing with Section 700D) of Division 3 of the Business OUTLETS OVER vv v1
and Professiora Code, and my license is In full force and effect. 5 PER SYSTEM % w"
t FINAL S -(C t VALIDATION
License Number Lic. Class DATE
FINALtzkr
Contractor Date BY
❑ I am exempt under See;
BAP.C. for this reason
Plan check fee
Date: PLUMBING PERMIT ISSUING FEES I c� 0 /
Signature TOTAL FEE �, Q -.✓ �'
-
Plan check applicant
SINGLE FAMILY
m,1 5 Q 9 A
HOME OWNER -BUILDER DECLARATION
Nome
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Address
- - -
• • • • • Jr
-
Professions Code):
City O T.I. N-.7yy 6t/
I -22500
1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
- -
_
• ° e 2 2.5 0
7044, Business and Professions Code).
-
,
9 T 2 - 8
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
ouch ' e reprelentotives of this County to enter upon the
ob a ention - open r' spection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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