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WQR,KERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
76A666 DPW 4/87
I hergoy, aft, that I have a certificafe of consent to self in- 76A667A
sure, or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86)
certified copy thereof (Sec. 3800,Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
❑ Certified copy is filed with the county building inspection ADDRESS
deparim nt. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
��®® i
Date Applicant — hY� M WATER CLOSET(TOILET) NEAREST /
CERTIFICAT OF EXEMPTION FROM'WORKERS' / BATH TUB CROSS'ST.
COMPENSATION INSURANCE OWNER
SHOWER
(This section need not be completed if the work involved by MAIL-
the permit is for one hundred dollars ($100) or less.) LAVATORY 00 ADDRESS
I certify that in the performance of the work for which this per- SINK CITY- TEL. NO.
mit is issued, I shall not employ any person in any manner so044—
as to become subject to the Workers'Compensation Laws. DISHWASHER
_ U /•� CONTRACTOR
Dat ApplicantJD.SSP� ^• /� ' M.� CLOTHES WASHER
ADDRESS l
NOTIC TO APPLI'ANT: If, after making this Certificate of Ex-
emption,you.should become subject-to the Workers'.Compen- CITY
.�� TEL. No.�
sation-provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATELIC.
ed. WATER HEATER LICENSE NO. CLASS
. LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCE ED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLET oa
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full-force and f- 5•PER SYSTEM FINAL VALIDATIO
fete. DATE C
License Number� Lic: Class V
F �
Contractor 7_ojr=Pdto BY 0
I am exempt un er Sec.
B.&P.C: for this.reason ►
� Plan check fee-
at Z PLUMBING PERMIT ISSUING FEE$
Signatur kyr
TOTAL FEE J�/
NGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5; Business and _
Professions Code): Address -
ia�. : y�r _5pE
I, as owner Cit of the property, will do the work and the Y Tel. No.
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structure isnot intended or offered for sale(Section 7044;
Business and Professions Code). ► E;.,%,: „?, A
CONSTRUCTION LENDING AGENCY -- r-)
I hereby affirm that there is a construction' lending agency for 44 '
the performance of the work for which this permit is issued
(Sec. 3097,'.Civ. C.).
Lender's Name5f 7`39
Lender's Address +'
I certify that I have read this application and state that the ► s
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representativ s of this County to enter upon the
above- entioned prop rty for i s ection p oseO
z SEE REVERSE FOR EXPLANATORY LANGUAGE
gn Lure of Pe mittee Date