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DECLARAT
WORKER'S I have
a certificate
of consent to 76A666DPW9/89 APPLICATION FOR PLUMBING PERMIT
76A667A
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab. C.)
I � —P—P _ � COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
Policy No/ mpany ��
A
Certified copy is h6reby furnished.
El
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building i' o ADDRESS
department. UMBER FIXTURE OR ITEM @ FEE LOCALITY
Date G Applicant / WATER CLOSET NEAREST C/
CERTIFICATE OF EXEMPTION FROM WORKERS' / CROSS ST.
BATH TUB
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the
SHOWER MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) LAVATORY OWNER AW
I certify that in the performance of the work for which this permit MAIL
is issued, I shall not employ any person in any manner so as to SINK ADDRESS G�
become subject to the Workers' Compensation Laws.
DISWASHER CITY G j EL.NO.
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR G
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS,J
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY �! e TEL.NO.
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER
STATE LIS
(commencing with Section 7000) of Division 3 of the Business and LICENSE NO. CLASS C�
Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS
OUTLETS OVER DISTRICT NO. PROCESSED BY Q
� ) 5 PER SYSTEM yI r Q
License Number _Lic.Class U
FINAL ;t i/ VALIDATION w
�' v , Date DATE y it
"Contractor
"C"T.
(:i ,a
FINAL
'f 1 C N—
I am exempt under Sec. � gY // L•J
B.&P.C.for this reason �_E e=f®�
Date:
Plan check fee Q 0 D
1
, t
1A'L m
Signature ./ ,t A PLUMBING PERMIT ISSUING FEE$ ,1�
b 65
TOTAL FEE s !O {CHECK 115.65
❑ E
Plan check applicant t- 1,3—t � _I
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law E t c t,�-
for the following reason (Section 7031.5, Business and Professions Address 'tJ."14111-00;1 •:/11JI'`e•:!
Code): qG7 1 i-tiilla 11
❑ City Tel.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 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 ins -pvrpasaS. SEE REVERSE FOR EXPLANATORY LANGUAGE
S'gnature of Permittee Date