HomeMy WebLinkAbout6860AWORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lob. C.)
Policy No. Company
Certified copy is hereby furnished.
❑' Certified copy is filed with the county building inspec-
tion deportment.
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 (S100) or less.)
I certify that in the performance of the work for which this
permit is Issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Lows.
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 [hat I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and effect.
License Number - Lic. Class
Contractor Date
❑ I am exempt under Sec.
B.&P.C. for this reason
Date:
Signature
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code):
❑ I, as owner of the property, will do the work and the
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
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 [hot 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.
ore of Permiltee Date
76A667A
CE 617 (REV. 10/61 }
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
SEE REVERSE FOR EXPLANATORY LANGUAGE
e is
5
FOR APPLICANT TO FILL IN (PRINT OR TYPE)BUILDING
ADDRESS
NUMBER
FIXTURE OR ITEM [1) FEE
LOCALITY
WATER CLOSET
NEAREST
CROSS ST.
BATH TUB
OWNER
SHOWER
LAVATORY
MAIL
ADDRESS
SINK
CITY TEL. NO.
DISHWASHER
CONTRACTOR -
CLOTHES WASHER
-
ADDRESS '
SWIMMING POOL RECEPTOR
CITY TEL. NO.
LAWN SPRINKLER SYSTEM
STATE LIC.
LICENSE NO. CLASS '
WATER HEATER
DISTRICT NO,
PROCESSED BY
GAS SYSTEM OUTLETS
OUTLETS OVER
5 PER SYSTEM
FINAL VALIDATION
DATE
FINAL
BY
►
Plan check fee
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
Plan check applicant
Name
Address
City Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
e is
5