HomeMy Public PortalAbout9034 JAYLEE DR_Plumbing_5/29/1985_fixtures WORKERS'COMPENSATION DECLARATION. np PIS L��C6 YMN FOR P(( U o NG PERn�',��5'(
I hereby affirm that I have a certificate of consent to self 76A667A uv u V uU Is uvu uvu u "
insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof (Sec. 3800, Lab. C. COUNTY.OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished.
F-1Certified
APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING,?
Certified copy is filed with the county building inspec- ADDRESS G�i �J
C_"40A
tion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITYCeGC� s�k
WATER CLOSET
Date ?Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE ' SHOWER OWNER G CL9 s
(This section need not be completed if the work involved by t
MAIL 4
the permit is for one hundred dollars ($100)or less.) LAVATORY �
� ADDRESS •
I certify that in the performance of the work for which this
permit is issued;i shall not employany person in any manner SINK CITY TEL.
so as to become subject to the Workers Compensation Laws. DISHWASHER
��•• ', y. CONTRACTOR
D � a� App , i' CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: l , after maki is Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL. NO.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PR SEED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS s�
(commencing with Section 7000) of Division 3 of.the Business OUTLETS OVER
and Professions'Code, and my license is in full force and effect. 5 PER SYSTEM FINAL /moi VALID ON @-
DATE /G l a f O
License Number Lic. Class
FINAL
Contractor Date BY
❑ �
I am exempt under Sec.
B.BP.C. for this reason
Plan check fee ;221 2 3.A Z
Date: PLUMBING PERMIT ISSUING FEE$. J� D # o`o o o o 5
Signature g TOTAL FEE 3 ; j� ,I o - 34,505
Plan check applicant
SINGLE FAMILY o529-85
HOME OWNER-BUILDER DECLARATION Name b
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and ) J�
Professions Code): City el. No.
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 that the D
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.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of mit ee Date