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WORKERS COMPENSATION DECLARATION 7 7; APPLICATION FOR PLUMBING PERMIT
I herebyaffirm that I have a certificate of consent to self CE 81ei7 7. 80)
insure or a certificate of Workers Compensation Insurance or I
fie copy the eo (S ab C) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Cc a
Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS
Certified copy is Bled with the county building inspection NUMBER FIXTURE OR ITEM •
Daterl ar e ,` }� LOCALITY
Applicant 04 AA" WATER CLOSET NEAREST /
BATH TUB CROSS ST "
oe
CERTIFICATE OF EXEMPTION FR M WORKERS
COMPENSATION INSURANCE SHOWER OWNER
RY MAIL
(This section need not be completed if the work involved LADDRESS a
by the permit is for one hundred dollars ($100) or less) O
SINK CITYB TEL NO V
I certify that in the performance of the work for which this DISHWASHER cc
permit is issued I shall not employ any person in any manner CONTRACTOR 0
so as to become subject to the Workers Compensation Laws CLOTHES WASHER ADDRESS r U
Date Applicant SWIMMING POOL RECEPTOR d
NOTICE TO APPLICANT If after making this Certificate of CITY TEL NO N
Exemption you should become subject to the Workers LAWN SPRINKLER SYSTEM STATE LIC Z
Compensation provisions of the Labor Code you must forth
with comply with such provisions or this permit shall be WATER HEATER LICENSE NO CLASS
GAS SYSTEM OL
deemed revoked ETS DIS T R ED B
LICENSED CONTRACTORS DECLARATION OUTLETS OVERS t
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM f
9 (commencing with Section 7000) of Division 3 of the Busi FINAL t VALIDATION
ness and Professions Code and my license is in full force and DATE
effect
�� I� FINAL
License Number��{,�SSe���c Class �+ , BY
Contractor ate
I am exempt from the licensing requirements as I am a Plan check fees
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051 Bus PLUMBING PERMIT ISSUING FEE$
mess and Professions Code) N �" " 1
a
a TOTAL FEE
Lic or Reg No Date Plan check applicant
r r
HOME OWNER BUILDER DECLARATION [AA.d'
me
I hereby affirm that I am exempt from the Contractors dress
License Lawfor the following reason (Section 7031 5 Busi y Tel No ..
ness and Professions Code)
I as owner of the property am exclusively contracting ( 2 2 0 a 3 A
with licensed contractors to construct the project i
(Section 7044 Business and Professions Code) l
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CONSTRUCTION LENDING AGENCY 2 �'� 2 2 0 0
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is o °to 2 2 0 0 v
issued (Sec 3097 Civ C)
Lender s Name 1 1 24-81
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing and hereby
authorize pr sent tives of this County to enter upon the
pr y for inspection purposes
gnatu e o rmi ee Date /