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WORKERS'COMPENSATION DECLARATION - APPLICATION FO PLUMBING PERMIT '
I hereby affirm that I have a .certificate of consent to self 76A667A �r M
insure, or a certificate of Workers'Compens9ti'on InsuranceA CE 817(REV. 1�) . - A
or a certified copy thereof(Sec. 3800, Lab. C.) '' COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company t �
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS �stPLE C
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
T
Date Appligont WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION•FROM WORKERS' /�
BATH TUB CROSS ST.. w D R KJ1o✓
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by MAIL
SHOWER d'YI /V i71. /��L
the permit is for one hundred dollars($100)or less.) LAVATORY DDRESSS_7 S3 Ar. 1 -In 14
I certify that In the performance of the work for which this p •�
permit is issued,1 shall hot employ any person in any manC•
marine, CITY'-� SPL C. f TEL. NO. d7 S%3�10
so as to become subject to the Workers'Compensation Laws. i DISHWASHERCONTRACTORP
\i"te 11-1-7-725 Applicant `7� CLOTHES WASHER.
NOTICE. TO APPLICANT: If, after making this Certificate of/ ADDRESS' S'/9 y� -
Exemption, you should became subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- ' [AWN SPRINKLER SYSTEM CITY TEL NO.
with. comply with such provisions or this ,permit shall be j STATE: LIC.
deemed revoked. WATER HEATER LICENSE NO: CLASS
LICENSED CONTRACTORS DECLARATION I DISTRICT NOROCESSEE)
I hereby affirm that I am licensed under provisions of Chapter 9 GAS.SYS7EM OUTLETS .S� /,.o
(commencing with Section 7000),of Division 3 of.the Business t OUTLETS OVER
and Professions Code,and my license is in full force and effect. 1.5PER SYSTEM. FINAL Jq
DATE VALIDATION u
License Number Lic..Class 2S
FI.N O
Contractor DateLU
I am exempt under Sec. �
rA
B•.&P.C. for this reason
- � Plan check.fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature I - 7 �'E A
TOTAL FEE S 0 0 6 0 0
Plan check applicant
SINGLE FAMILY
HOME OWNER-.BUILDER DECLARATION Name yrt'R en A v(f R A•M I/Z:F 2—
I
I hereby affirm that.I am exempt from the Contractor's License Address..5
Law for the following reason (Section 7031.5, Business and S 7 Al. l -E.M. e f C iT 161--
City
L.
Professions Code): City 41,-'14 F C•lT Tel. No- 7364 1 1.2
❑ 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 constructlon.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 informciflon is correct. I agree to comply with a((County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned propert for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
/ Signature of Permittee Date