HomeMy Public PortalAbout10529 BOGUE ST_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I hove a certificate of consent to self 76A667A
insure, or a certificate of Workers' Compensation Insurance, CE 817(REV 10/81)
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished.❑ BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE)
Certified copy is filed with the county building inspec-
ADDRESS
tion department. NUMBER FIXTURE OR ITEM a FEE
ii LOCALITY
Cl
zt
Date Applicant WATER CLOSET 1 NEAREST /)
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB j CROSS ST r
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars $100 or less. MAIL
JF
P ( ) ) LAVATORY ADDRESS
I certify that in the performance of the work for which this )��/
permit is issued, I shall not employ any person in any manner SINK CITYeLce
TEL NO`T73_
so as to become subject to the Workers'Compensation Laws DISHWASHER J f 7
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate-of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL NO
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER / r LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION �[i DISTRICT NO OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER O
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM C'
FINADATEL VALIDATION
License Number Lic. Class
FINAL O
Contractor Date BY /-✓ "�'�- S
F-1
I am exempt under Sec. �
N
B &P C for this reason Plan check fee ► Z
Date PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License %995 5 A
Law for the following reason (Section 7031 5, Business and Address
Professions Code): by Tel. No f, ojo 0 0 o 5
❑ I, as owner of the property, will do the work and the Z o o 9 5, 0 0
k• 6
structure is not intended or offered for sale (Section o 0 o 95006
7044, Business and Professions Code)
poll.CONSTRUCTION LENDING AGENCY O 3 2 v—8 4
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'sAddress
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
oyphVoned prop for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sigh4ure of Permittee Date