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woxxeres'CONPENSATIONDF.CLARATION �••"•�� APPLICATtON FOR PLUMBING PERMIT �
1 hereby a(firm Ihal 1 Fiave a'rertificate ef consent to self ee.n(e-eo) .� ,
insure,or a cerNficate ol Workers'Compensation Insurance,or , , '
a certified copy thereof(Sec.3800,Lab.C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company .
� CertiCed copy is hereby furnished. � FOR APPLICANT TO FILL IN(PRINT OR TYVE) BUILDING
ADDRESS / � �
� Certified copy le tiled�vlth the county building inspectfon NVMBER FIICTURE OR ITEM. • FEE , -
departmenL LOCALITV O�y
WATER CLOSET
Date Appiicant NEAREST(� t� .
BATHTUB CROSSST.\J� •Q�vV1 �
CF.RTIFICATE OF EXEMPTION FROM WORKERS'.
" COMP6NSATfONINSURANCE SHOWEq OWNER �
LAVATOPV MAIL }
(This section need not be completed if the work involved ' qoDRESs J� �sJl�e a-
by [he permit is [or one hundrai dollars(S100)or IessJ SINK �
CITY T
I certify Ihat in ihe performence nf the wark tor which this DISHWASHER �
CONTRACTOR y
permit is issued,1 ahall not em loy any erson in any manner O
so as to become subject to the W e � ensalion Laws. CLOTHES WASHER A�DRESS � � U
Da[e���'ay,Appticent SWIMMING POOL RECEPTOR d
NOTICE TO APPLICANT:If,after making ihis Certificate of CITV TEL.NO. y
Exemption, you should become suAject fo the Workers' LAWN SPFINKLER SYSTEM STATE LIC. 2
Compensetion provisions of the Labor Code,you mvat forth- LICENSE NO. CLASS
with comply u•ith such provisions or this permit shall be WATER tiEATER
Seemedrevoked. ! D� DtSTRICTNO. PROC SSE�BY
GASSYSTEM OUTLETS
LICENSEU CONTRACTORS�GCLARATIQN OUTLETS OVER �0 Rtw—�—✓
1 hereby affirm ihat I am licensed under provi6lons of Chnpter 5 PER SYSTEM /
9(cammencing with Sedion 7000)of Dirisinn 7 of the Rusi- FINAL (!�` /� VALIDATION
ness and Professions Code,and my Iicense is in full force and �d bATE � 'V� � •
eftect. /'
License Numher Lic.Class , 8Y AL� (,(Q6�IIT�,�
C
Controctor Dete �
� i am ezempl from the licensing requirements as I am a Plan check fee � ;
licenud architect or a registered professional engineer pLUM6tNG PERMIT ISSUING FEE E S� .
ac[ing in my proPessional cnpacity(Seclion 7051,Bus- .
inect and F'rofessions Code). TOTAL FEE /G. Sa
Lic.or Re6�No. Dafe plan c�eck applicant � 3��O 2� A :
�
HOM1tEOWNF'R-BUILDF,RnBCLARATION Name � ���'i�'��1J �
1 here6y affirm that 1 am exempt from the Contractnr's Addresc I'• •.1 650 �
License Law for the fnilnwino re,sen!��c!!^.^.?03L5,Bw: Ci�v � 7e1.No. '
ness and proPossions Code): � � �1 6 5 0� --
� f,as owner of Ihe property,am exclusively contracting � 2 1 Jr z$.1 �
atith licensed mntractors to rnnsfruct the project �
(Sectan 7044,Business and Profasinns Code). ,
CONSTRUCTION LEND[NG AGENCY
I hereby aifirm that there is a construction lending agency
for the performence af the work tor which ihis permit is
issued(Sec.3097,Civ.C.). .
Lender's Name
I
� Lender's AdJress
I certify that I have read this application and state that the �
a ove informaU is correct.I agme to compiy with all Counfy SEE AL•VGRSF FOR @XPLANATORY LANGUAGE -
o Inance a S[ la regulating Plumbing, and hereby .
au mi ¢ ntat es Ihis County to enter upon the .
abo e-m ' n p ope inspectinn purposes. -
X � �
Si ntureoiPermittee Date
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