HomeMy Public PortalAbout9315 BROADWAY_Plumbing__ V/4�RKERS'COMPENSATION DECLARATION
APPLIcATION FOR PLUMBING PERMIT
V!. Hereby.affirm 'Swot I have a certificate of consent to self76A667A .
insure. or a certficate of Workers Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof (Sec. 3800, Lab. G) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING n .
Certified copy is filed with the county building inspec- ADDRESS -13 5 Cr l.'.}.
tion department. NUMBER FIXTURE OR ITEM E FEE ,
LOCALITY C 1 E�gl)
Date Aprlpli4onl WATER CLOSET /
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST, .e S,t
COMPENSATION INSURANCE OWNER L•w.
(This section need not be completed if the work involved by SHOWER O _A ti
MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS C1 3 5i 1 I .¢-�W
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 c; TEL. NO O
so as to becomes bject to the Workers'Co ensation aws. DISHWASHER ` I,t
(�' CONTRACTOR
Date Applicant f CLOTHES WASHER ADDRESS
fi
NOTIC TOA LICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exem ion, ou should become subject to the Workers' CITY TEL NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
• with comply with such provisions or this permit shall be
STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICJ NO OCESSED BY
I hereby off irm tha `'/S't I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS lfy
(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 FINALJ Q �//� ATION >;License Number Lic. Class DATE G a
O
FIN U.
ContractorDate BY
❑ 1 am exempt under Sec. 2 6 4 3 5 A
B.BP.C. for this reason W
Plan check fee D # ° ° ° ° ° 5
—Date:— En
PLUMBING PERMIT ISSUING FEE 3 S ) o - 21R50 Z
Signature
TOTAL FEE e o o2a5OV
Plan check applicant
SINGLE FAMILY c 1.2 9-'87
HOME OWNER-BUILDER DECLARATIONName '
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
Professions
ICode): City Tel. No.
LCI. 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section D ,
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 D
above information is correct. I agree to comply with all County r
ordinances and State laws regulating Plumbing, and hereby
authorize representotives of this County to enter upon the
d ave-meni' ned propertt for inspectionpurp ses.
C` .6n� SEE REVERSE FOR EXPLANATORY LANGUAGE
r / I d L6
Signature of Permittee Da '