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Home My WebLink AboutNo Permit Number (22)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 c thereof (Sec. 38MO. LO& C. ) Policy Company. Certified copy is hereby furnished. Certified copy is filed with the county buildin inspec- tion depart tit. DateApplicant ERTI CATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE This setdion need not be completed If the vtork Involved by the permit Is top one handrail dollars ($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' Comperrantion Laws. Date Applicant t'TO APPLICANT: If, after making this Certificate of I Action, you should tzecome subject to the Workers' Compensation provisions of the Labor Code, you must forth. with —Filly with such provisions or ibis permo stiou be deemed revoked. LICENSED CONTRACTORS WAARATION I hereby affirm ships I am licensed under pp wb igrg Rf ChWW 9 cornmorrcing with Section 7MQ) of 4irision 3 of the Business and Firofess.. Code, aril my license is in full forcjfe SSand affect. License Number ic. Classes Canvoctcr 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 OAS s4mm s OUTLETS Fk fee PLUMBING PERMIT ISSUING FEE S TOTAL FEE Leader's Nome Lender's Asidress I terrify that I hove read this application and state that the above information is correct. I agree so comply with all County ordinonces and State lows regulating Plumbing, and hereby authorize representatives of this County to enter upon the 1scr,hine.l.oned properly for inspection purposes. `` Signature of Permmee T Tel. No. SEE REVERSE FOR EXPLANATORY LANGUAGE pTv Plan check applicant SINGLE FAMILY OWMACTOR HOME OWNER -BUILDER DECLARATION Nome spy affirm that I am exempt from the Contractors Lican L-11or the following reason (Section 7031.5, Business Ond gess Professions Code): City UWSS I, as owner of the property, will do the work and the LLCEA NSE ND. structure is not intended or offered for sale (Section 7044, Business and Professions Code). PROCESSED BY CONSTRUCTION LENDING AGENCY FINADATEL I shotaffirmgt there is a construction lending agency for the performance of the work for which this permit is issued Sec. 3097, Civ. C.). Leader's Nome Lender's Asidress I terrify that I hove read this application and state that the above information is correct. I agree so comply with all County ordinonces and State lows regulating Plumbing, and hereby authorize representatives of this County to enter upon the 1scr,hine.l.oned properly for inspection purposes. `` Signature of Permmee T Tel. No. SEE REVERSE FOR EXPLANATORY LANGUAGE pTv v TEA. !! OWMACTOR 95, ADDRESS CITY TEy UWSS LLCEA NSE ND. 3 DIStRICT NOJ D PROCESSED BY FINADATEL VA DATION G V FINAL aC 5Y H W IL z: i 00 2 Q 0 cn CA 3 0Io.31 lI ln2(2§ q|eli±o 0 Iwo 'a' Z,4 C, n.c .,: F ID0 3L 3L | 7 ,:- .k.=2pa r£, 2«+ (]&,k 7 $-&\|f%& zQ,— a}'/}af% CL E[e(\7§ E is;;f$[!e»&ez n k 2 3 0Io.31 lI ln2(2§ q|eli±o 0 Iwo 'a' Z,4 C, n.c .,: F ID0 3L 3L | 7 ,:- .k.=2pa r£, 2«+ (]&,k 7 $-&\|f%& zQ,— a}'/}af% CL E[e(\7§ E is;;f$[!e»&ez I y 2 9 3 0Io.31 lI ln2(2§ q|eli±o 0 Iwo 'a' Z,4 C, n.c .,: F ID0 3L 3L | 7 ,:- .k.=2pa r£, 2«+ (]&,k 7 $-&\|f%& zQ,— a}'/}af% CL E[e(\7§ E is;;f$[!e»&ez