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WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76g667A
insure,ora certificate of Workers'Compensation Insurance, CE 817(REV.10/81)
or a certified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No, Company
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM a) FEE
LOCAUT
WATER CLOSET
ADateApplicantNEAREST
CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB
COMPENSATION INSURANCE OWNER
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t
This section need not be completed if the work involved by
SHOWER
the permit is for one hundred dollars($100)or less.) MAIL
LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner SINK CIT AM TEL NO.
so as to become subject to the Wo kers'Compensation Laws.
DISHWASHER
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p CONTRACTOR
Date
J
I_` b Applicant lAAer CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CCTV TEL.NO.
Compensation provisions of the Labor Code,you must forth-LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO, PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS QC
commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full farce and effect. 5 PER SYSTEM FINAL )VALIDATION
DATE AL3OrLicenseNumbertic.Class
1 FINAL C.D
Contractor Date BY W
1 am exempt under Sec.
j B.&P.C.for this reasonPlancheckfeeT
Data:FiPLUMBINGPERMITISSUINGFEE$ /() V
i Signature j y,
TOTAL FEE A J t r
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i Plan check applicant
iISINGLEFAMILY
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HOME OWNER-BUILDER DECLARATION No..
1 hereby affirm that 1 am exempt from the Contractor's License a AddressLawforthefollowingreason(becnon l03i.5,Business andr: Profess'- Code: j "+ 1 O O itCityTel.No. y
I,as owner of the property,will do the work and the ti 4- B&
G_ structure is not intended or offered for sale(Section ;
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for t
the performance of the work for which this permit is issued l
Sec.3097,Civ.C.).
i
Lender's Name
Lender's Address I
t I certify that I have read this apphcotlon and state that the
1, above information is c rrecL I agree to comply with all County ,
ordinances and Stale laws rlu"ng Plumbing,and hereby
authora a se Ives bfo ty 10 enter upontheperryfkionpurpases)
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Jed11 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date t
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