HomeMy Public PortalAbout9981 BOGUE ST_Plumbing__ WORKERS'COMPENSATION DECLARATION AI�PUCATION FOR PLUMBING PER
I hereby affirm that I have a certificate of consent to self 76A667A
insure, or a certificate of Workers' Compe ation Insurance, CE 817(REV 10/81)
or a certified copy thereof (Sec. 3800, La C ) COUNTY OF LOS ANGELES B ILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished
J FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
71
}LA1/JI Certified copy is filed with the county building i c- ADDRESS
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tion epart ent. NUMBER FIXTURE OR ITEM FEE
LOCALITY
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF-EXEMPTION OM WORKERS' 7 BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by MAIL V
99 /
the permit is for one hundred dollars (:100)or less.) LAVATORY ADDRESS 7'
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 CITY TEL. NOl�/W-7D j
CONTRACTOR
so as to become subject to-the Workers'Compensation Laws DISHWASHER 7
- �
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT- If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject To the Workers' CITY TEL NO o
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply' with such provisions or this permit shall be STATE Q LIC
deemed revoked WATER HEATER LICENSE NO Q CLASS C
LICENSED CONTRACTORS DECLARATION DISTRICT NO ROCESSED BY
.1 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 r
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
_IS VALIDATION u
�f DATE'
License Numb i ( Lic Class C r3 ? �C
FINAL
Contractor
O
Contractor Date BY '
El Lu
I am exe u er ec 0.
B&P C. for this reason
Plan check fee
Date: .es >•
PLUMBING PERMIT I SI (tFE $ ` a
Signature
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 Address
Professions Code): City Tel. No. zy# 0 0 010 fo•5
ElI, as owner of the property, will do the work and the '�'o -1`6,5:0
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
16-50=
CONSTRUCTION LENDING AGENCY ± '
I hereby affirm that there is a construction lending agency for 0'], 3'-8,3
the performance of the work for which this permit is issued
(Sec. 3097, Civ C )
Lender's Name
Lender's Address
I certify that 1 have read this application and state that the ►
above information is correct I agree to comply with all County
ordinances and State jaws regulating Plumbing, and hereby
authorize representat of this County to enter upon the
above-mentioned p pe y for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ature of Permittee ate