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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 cert;ificata of Worker's Compensation Insurance, or a certified
copy thereof(Sec. 3800 Lab. C.)
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
Policy No. Company
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING�pr� A ' D tI
❑ Certified copy is filed with the county building inspection ADDRESS IIJJ 1\ �s3
department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY
Date Applicant WATER CLOSETS NEAREST k�
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
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($100)or less.) ' OWNER
I certify that in the performance of the work for which this permit l LAVATORY L
is issued, I shall not employ any person in any manner so as toSINK MAIL
ADDRESS
become subject to the Workers'Compensation Laws.
DISWASHER CITY -�'w M s^' TEL.NO.Z?L•_
Date Applicant CLOTHES WASHER ` CONTRACTOR iFG u
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO. �-
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER
(commencing with Section 7000) of Division 3 of the Business and -STATE LIC. 0
Professions Code,and my license is in full force and effect. GAS SYSTEM a OUTLETS LICENSE NO. CLASS
OUTLETS OVER DISTRICT NO. PROCESSED BY cc
5 PER SYSTEM
License Number Lic.ClassI—
FINAL
DATE VALIDATION Id�A
t�~ 0.Contractor Date
❑ I am exempt under Sec. FINAL
BY
B.&P.C.for this reason
Date: an O , ». 'E:rY xi
Signature
PLUMBING PERMIT ISSUING FEE$
❑ TOTAL FEE
Plan check applicant '
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name -
I hereby affirm that I am exempt from the Contractor's License Law — -- •�- ?•_
for the following reason (Section 7031.5, Business and Professions Address "•t_—r•'r
5.rt i��•S•i
Code):
City Tel.No.
I, as owner of the property,will do the work and the structure r'''r`-'^• j_'
is not intended or offered for sale (Section 7044, Business
and Professions Code). ,
.'jai°`.14..i—,`.y;� .^.•t :.�„'r'N'
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the _�,,_ i ;tj•I •., -
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
pr a or ins pec' n ses -1.2 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date