HomeMy WebLinkAboutNo Permit Number (1323)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 copy thereof (Sec. 3800, Lab. C.)
Policy No. Company
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection,,
Date' Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need, not be completed if the work involved
by the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
Permit is issued, J,shall not employ any person in any manner
so. as to become' -subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION..
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in'full force and
effect.
License Number Lic. Class
Contractor Date
I am exempt from the licensing requirements as I am a
licensed architect or' a registered professional engineer
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code).
Lid.. or Reg. No. Date
HOME OWNER -BUILDER DECLARATION
' I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section. 7031.5, Busi-
ness and Professions Code):
FI, as owner of the property, am exclusively contracting
with licensed contractors to construct the project
(Section 7 44, 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
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County -to 'enter upon: the
above-mentioned property for inspection purposes„
Signature of Permittee Date
OUTLETS OVER
5 PER SYSTEM
FINAL
DATE VALIDATION
FINAL
BY
�Ra17 (z-80) APPLICATION FOR
PLUMBING
PERMIT
COUNTY OF LOS ANGELES,
j
BUILDING AND SAFETY
BUIO.-ING
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
ADDR, �S
'NUMBER FIXTURE OR ITEM FEE
y
r"
LOCALITY
WATER CLOSET
NEAR.rST
BATH TUB
CROs, ST.
SHOWER
OWNER -.
LAVATORY
MAI L
A;bDRESS
SINK
CITY
T,EL. NO.
DISHWASHER
CONTRACTOR
CLOTHES WASHER
ADDRESS
SWIMMING POOL RECEPTOR
CITY rvv
.TEL. NO.
LAWN SPRINKLER SYSTEM
STATE
LIC.
WATER HEATER
LICENSE NO. a
CLASS
DISTRICT NO.
PROCESSED BY
GAS SYSTEM OUTLETS
OUTLETS OVER
5 PER SYSTEM
FINAL
DATE VALIDATION
FINAL
BY