HomeMy Public PortalAbout9042 ACASO DR_Plumbing_12/2/1986 WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
,1:ihereby affirm that I have a certificate of consent to self 76A667A
insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
or d 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 @ FEE LOCALITY
WATER CLOSET
Date Applicant NEARESST. ��jp'
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB SROSS
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER
MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL, NO.. 9 A'
so as to become subject to the Workers'Compensation Laws.
DISHWASHERCONTRAGOOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such ,provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION r DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER V(�
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM
FINAL/ '7 VALIDATION
DATE ` _z
License Number Lic. Class 0
FINAL U.
Contractor Date BY
I am exempt under Sec. O�
U
B.BP.C. for this reason Lt.l
Plan check fee ® CLI
Date: C/)PLUMBING PERMIT ISSUING FEE$ (? Z
Signature ®'
TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address r
rfions Code): City Tel. No., 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). 2 5 51.3 A
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for # 0.0 0 0 0 5
the performance of the work for which this permit is issued 0 0 3 L�5 0
(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 presentatives of this County to enter upon the
ab ntioned o or inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
CAWA�� V, g-
Signature of Perm' ee Date