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4 WORKERS' COMPENSATION DECLARATION
—b,r,nfhrm thol I have n certificate of consent to self
,re, cr a certificate of Workers' Compensotion Insurance,
I )cend.ed copy thereof (Sec. 3800, Lob. C.)
Policy Na. Compony
Certified copy is hereby furnished.
Certified copy is fled with the county building inspec-
tion deportment.
Dote Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need net be completed If the Werk Involved by
she permit Is for one hundred della- (5180) or s.)
I cen,(y that in the perfa.manco of the wo which this
permit is issued, 1 shall not employ any in any manner
so as
pe—n:
become suli to the Worke socio ows.
Date APPlicon
NOTICE TO APPLICANT: If, of*r king t Car scale o
Exemption, you should beco subject o th Workers'
Comoensation provisions of the Labor C e, must forth-
with comply with such provisions or t ermit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
1 hereby offirm that i am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my licerx is in full force and effect.
License Number Lic. Class
Contractor fate
C] I am exempt under Sec.
B. BP.C. for this reason
Dote:
Signature
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I hereby offirm shot I am exempt from the Conlroctor's License
Low for the following reason (Section 7031.5, Business and
r es i Code):
1
I, 05 as owner of the property, will do the work and the
s'ructure is not intended or offered for sale (Section
70", Business and Professions Code).
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
Its"
der', Address
I certify that I have read this application and slate that the
above information is correct. I agree to comply with oil County
ordinance nd Slate laws r ulating Plumbing, and hereby
aulhori r esento ves !his County to enter upon the
obov m ed for in coon purpos
`lanolure of Per ee Dote
APPLICATION FOR PLUMBING PERMIT
76AS67A
CE 817 (REV. 8/86)
COUNTY OF LOS ANGELES
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
NUMBER FIXTURE OR ITEM V FEE
WATER CLOSET
BATH TUB
SHOWER
LAVATORY
SINK
DISHWASHER
CIOTHES WASHER
SWIMMING POOL RECEPTOR
LAWN SPRiNKLER SYSTEM
WATER HEATER
GAS SYSTEM OUTLETS
Plan check fee
PLUMBING PERMIT ISSUING FEE S
TOTAL FEE
Plan check applicant
Name
Address
City Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
DEPT. OF PUBLIC WORKS
CAM ST. 1 --VA 7 - V & sV
OWNER 6 $iLT
MAIL
ADDRESS w/-'"457 �S ✓�
CITY
CONTRAC70R�r
ADDRESS
CITY TEC NO.
STATE LIC.
LICENSE NO. CLASS'
DISTRICT NO. P(LQCFSSED BV
pNAI 41 VALIDATION
FINAL /_
By / 'O
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