HomeMy WebLinkAboutNo Permit NumberWORKERS' 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 c thereof (Sec. 38MO.
LO&
C. )
Po licyN Company.
Certified copy is hereby furnished.
Certified copy is filed with the county buildin inspec-
tion depart nt.
Date Applicant
ERTI CATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This setdion need not be completed If the work Involved bythepermitIstoponehundreddollars ($100) or Ins.)
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
sa as to become subjW to the Workers' Compensation Laws.
Date Applicant
t'TO APPLICANT: If, after making this CemYicate of
I Ajtion, you should t,Tecarhe subject to the Workers'
Compensation provisions of the Labor Code, you must forth.
with —Filly with such provisions or ibis permit stiou be
deemed revoked.
LICENSED CONTRACTORS WAARATION
I hereby affirm shot I am licensed under preris;grg Rf ChWW 9
corgmertcing with Section 7MQ) of 4;rision 3 of the Business
and Rofess;oro Code, and my license is ;n full forcjfe
SSand
affect.
License Number ic. Classes
Canvoctcw re 2
1 am exempt under-'
B.BP.C. for this reason
Dote:
76A667A APPLICATION FOR PLUMBING PERMIT
CE 817 (REV. )0/81)
COUNTY OF LOS ANGELES
FOR APPLICANT TO FILL IN (PRIM OR TYPE)
FIXTURE OR ITEM
WATER CLOSET
BATH TUB
SHOWER
LAVATORY
CLOTHES WASHER
SWIMMING FOOL RECEPTOR
LAWN SPRINKLER SYSTEM.
WATER HEATER
GAS s4mm s OUTLETS
Fk fee
PLUMBING PERMIT ISSUING FEE _
TOTAL FEE
Leader's Name
Lender's Asidress
1 terrify that I hove read this applicalion and state that the
above information is correct. I agree so comply with all County
ondinonces and State lows regulating Plumbing, and hereby
authorize representolives of this County to enter upon the
bcrv nnimlroned properly for inspection purposes. `
Signature of Permmee T
Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Pry
Plan check applicant
SINGLE FAMILY
WNTRACTOR
HOME OWNER -BUILDER DECLARATION Nome
spy affirm that I am exempt from the Contractor', Licerne
I. --for the following reason (Section 7031.5, Business Ond gess
Professions Code): City
I, as owner of the property, will do the work and the
itr ND.
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
PROCESSED BY
CONSTRUCTION LENDING AGENCY
FINADATEL
I hereby affirm shot there is a construction lending agency for
the performance of the work for which this permit is issued
Sec. 3097, Civ. C.).
Leader's Name
Lender's Asidress
1 terrify that I hove read this applicalion and state that the
above information is correct. I agree so comply with all County
ondinonces and State lows regulating Plumbing, and hereby
authorize representolives of this County to enter upon the
bcrv nnimlroned properly for inspection purposes. `
Signature of Permmee T
Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Pry v TEA. !!
WNTRACTOR
95,
ADDRESS
CITY
TEy
itr ND. A- 55 — 3
DIStRICT NOJ D PROCESSED BY
FINADATEL VA DATION G
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