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WORKERS'COMPENSATION DECLARATION iswes�w � �
I hereby aPfirm �ha< < he�e a'certifcate of�onse„�to se�F �E.,�,�-.o, APPLICATION FOR PLU MBlNG PERMIT
insure,or a certificate ot Workers'Compensation Insurance,or
u certified copy[hereof(Sec.3800,La6.C.) �
Policy NW'-��Company u/L�� —��IS`_ COUNTY OF LOS ANGELES, fiUILDtNG AND SAFETY
� � Certified copy is hereby furnished. FOR APPLICANT TO FI�L IN(PRIN7 OF TYPE) BUIL�ING
AD�RESS �� �F
� Certi�ed copy�G{ed with t county b 'Iding ins �tion NUMBER FIXTURE OR ITEM • FEE �
Date�8 � WATER CLOSET LOCAUTY ,
Applicant NEAREST �
BATH T V B C RO55 ST. �
CERTIFICATE OF EXEMPTIDN FROM WOA RS'
COMPENSATIONINSURANCk: SHOWER OWNER �
LAVATORY Ma��' !
(This seclion need not be completed if tLe woik invoWed ADDReSs �
6y the permit is for one hundced doltacs (SI00}or Iess.) SINK a �
CITY TEL.NO.
1 certity that in the performance of the work for which this DISHWASHER �
permit is issued,1 shatl not employ any person in any manner CONTRACTOR � �
so as to Aecome subject ta the Workers'Compensation Laws. CLOTHES WASHER �
Date Applicant ADDRESS �� � � O �
SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT:If,after making this Certificate of CITY ���� TEL.N W i
Exemption, you shou[d become subject to the Wurkers' LAWNSPRiNKLERSYSTEM a� ~ 0. �
Cumpensation provisions flf the Labar Code,you must forth- STATE �tC. U) �
with comp(y with such provisions or this permit shxll be WATER HEATER uCENSE NO.� _ CLASS �—a.7 �
s
deemed revOked. ��STRICT NO. PROCESSED B �
GASSYSTEM OUT�ETS � ��`C �
L[CENSEU CON'IRACTORS DECLARATION OUTLETS OVER t
1 hereby affirm that[am Licensed under provisims uf Chapter 5 PER SYSTEM
9 (commencing with Section 7000)uf Division 3 of the Busi- FINqL �
ness and Professions Code,and my Licente ix in full force and �A7E VALIDATION
effect.
f''� /l� ��,� G_ FINAL �
License Number�.{.`t-F� Lic.Ctass � gy
Conttac[or�v0__�___� Date �`���t5 � €
� I am exempt trom ehe ticensing requirements as t am a Plan check fee
�
licensed archHeCt or a regis[ered professionul engineer pLUMBING PERMIT ISSUING FEE$ � �
acting iw my profeasionai capacitp (Seetion 7Q51, Hus-
inesa and Professions Code). �7 � �
TOTAL PEE oL
Lic.or Reg.No. Date Plan check applicant
i
HOME OWNER-BUIL�F.R�ECLARATION Name I
1 hereby affirm that [ •em exempt from the Coatructor's
Addreas ' ' ? ��,r� �
License Law fnr [he foflowing reason (Sec[ion 7031.5, Busi- CitY Tel.No. ., • e s e� �
ness nnd Prafesaions Code): � � ,
_ � I,as uwner of the property,am exclusively conttacting �' ��� '-��� i
with licensed contractorx to construct the pruject •�n.� •`�? �
(Section 7044,Business and Protessions Code). � � �� � j
u';t � !—f?1 �
CONSTRUCTION LENDING AGENCY
1
i hereby affirm that there is a cons[ruction Iending agency ,
for [he pertormance of the work for which this permit is �
issued(Sec.309�,Civ.C.).
Lender's Name �
�
Lender's Address �
4
I certify that I have read this application and state that the �
above informntion is correct.[agree[o comply with alJ County SEE REVERSE FOR EXPLANATORY LANGUAGE:
ordinances and State laws regulating Plumbing, and hereby �
� autho'ze representatives of hi County to enter upon the �
abov' entioned y f i ection purposes. �
_ --/l 8 i
S�g n ute ot Permittee ate �
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