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WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT f
r -r r affirm that;I have a certificote of consent to self 76A667A ` b x
o a cerfificare of Workers Compensation Insurance CE 817(REV 10/81)
o a 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 �� 4015:
�
Certified copy is filed with the county building inspec ADDRESS �]'�/pC.CQ /f/y
a a tion department a i s NUMBER FIXTURE OR ITEM s (Crit 4 FEE LOCALITY
Date Appligant it I WATER CLOSET ` J NEAREST
J x `
ST OF EXEMPTION FROM WORKERS BATH TUB CROSS ``� xJ/ g4t r l A
-
COMPENSATION INSURANCE r �s { f� OWNER i,�� /y.
(This section need not be completed If the work Involved by SHOWER r c /'v /fj/// - p 4
the permit Is for one hundred dollars($100)or,less)s f, MAIL Z I LAVATORY '� „ � '� ADDRESS
I certify that in the performance of the work for which this c ti
permit is Issued I shall not employ any person in any manner 1 SINKB CITY TEL NO r
a
so as to become subject to the Workers Compensation Laws ~r DISHWASHER
a ? t CONTRACTOR i
'Dote Applicant r e CLOTHES WASHER I i
r NOTICE TO APPLICANT If after making this+Certificate of , t ! M ADDRESS 1
Exemption you should become subject to the Workers '� v , SWIMMING POOL RECEPTOR ^ r
Compensation provisions of the Labor Code you must forth + s CITY r TEL NO
F LAWN SPRINKLER SYSTEM a
with comply with such provisions or this permit shall be
STATE LIC
deemed revoked t { WATER HEATERt r j ;+ LICENSE NO CLASS r
LICENSED CONTRACTORS DECLARATION 1 DISTRICT NO PJZOCESSED BY
a GAS SYSTEM OUTLETS
r I hereby affirm that I am licensed under provisions of Chapter 9 t q a
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER + t A #
- and Professions Code and my license is in full force and effect 5 PER SYSTEM116
DATE w f VALID N V
FINAL s
. License Number Lic Class
rFIN 40
t Contractor j Date ^! ! BY a { q # 12 Q3
w E] I am exempt under Sec ::: 1
r
5 ry ! N
1 1 + 3 z
B&P C for this reason i i
Plan check fee
Dare `' � I°°'° 2 a Jc Qi f
+ PLUMBING PERMIT ISSUING FEE$ ° ° 02a50'2. 10-84 2 Jr Qrmr
Signature v
TOTAL FEE OC 1 21 Q-8 4 '
r W a �
s Plan check applicant r
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION ti Name P \ x r
I hereby affirm that I am exempt,,from the Contractor s License Address 1 r �s r K Ti I I R
Law for the following reason (Section 7031 5 Business and I`"
Professions Code)5q9 n City , Tel No t y
i t a
I ,as owner of the property will do the work and the s a
structure is not Intended or offered for sale (Section
7044 Business and Professions Code) ` 1 ' r ,
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 ' s ' ' "r 1 '
(Sec 3097 Civ C )
1
Lendep„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 lows regulating Plumbing and hereby r r
authorize representatives of this County to enter upon the-
above oned property for inspection purposes is 4r f 9 !
SEE REVERSE FOR EXPLANATORY LANGUAGE
' +e ! 9 1 4%
Signature of Permittee
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