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WORKERS'COMPENSATION DECLARATION 81 ; e ) APPLICATION FOR PLUMBING PERMIT
I hereby, a CE affirm that I have certificate of consent to self e» z- o
in or-a certificSte of Workers'Com sation Insurance,or
4oWCN
c y thereof(Sec. 3800, ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
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Certified copy is hereby turn' hed. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING d
Certified copy is filed with the unt building inspection NUMBER FIXTURE OR ITEM • FEE ADDRESS
l e LOCALITY �tf`►
//(Date pplicant WATER CLOSET L� I
NEAREST
BATH TUB CROSS ST. �2
CERTIFICATE OF EXEMPTION FROM WO RS'
COMPENSATION INSURANCE SHOWER OWNER
MAIL
T
AVAORY J LAjL�
(This section need not be completed if the work involved L �_
A D D R E S�(/-q IV
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by the permit is for one hundred dollars ($100) or less.) SINK TEL. NO. a
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I certify that in the performance of the work for which this DISHWASHER
permit is issued, I shall not employ any person in any manner CONTRACTO � O
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER
ADDRE e 1 7C'P,// 7,,) O
Date Applicant U! I' ` U
SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT: If, after making this Certificate of CITY Qwt� TEL. NO. �C/kf LU
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM " d
�! STATE LIC. _J C� W
Compensation provisions of the Labor Code, you must forth- LICENSE NO. IZ? CLASS J
with comply with such p WATER HEATER
p y provisions or this permit shall be
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. O S D BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVERl�
I hereby affirm that I am licensed under provisions of Chapter 5 PE YSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL J VALIDATION
ness and Professions Code, and my license is in full force and DATE z j—O
effect.
117 q 2-Z�7 C `S � FINAL
License , ` Lic.ClassgYContract• Date `��
I am exempt from the licensing requirements as. I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code).
TOTAL FEE
Lic.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Address n
License Law for the following reason (Section.7031.5, Busi- City Tel.No. c 1 •7 L!,7 A
ness and Professions Code):
# 000005
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project 2 0 0 Q
(Section 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY o 0 0.1 3,0 0
I hereby affirm that there is a construction lending agency �,2 9781
for the performance of the work for which this permit is
issued(Sec. 3097,Ci .Cr).
Lender's Name
Lender's Address I v17
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and tate ,a regulating Plumbing, and hereby
authorize rep ese tatives of this County to enter upon the
above-menti ed oper for inspection purp ses.
1
Signature of P rmitt a Dat j