HomeMy Public PortalAbout9574 BROADWAY_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
hereby affirm• that i-hove a certificate of consent to self 76A6p7A r
insure, ar a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF ANGELES BUILDING AND SAFETY
Policy Na. Company _ '
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN.(PRINT OR TYPE) BUILDING _-
Certified copy is filed with the county building mspeo- ADDRESS
tion department. NUMBER FIXTURE OR ITEM C FEF p
/7 / �• LOCALITY 1 I C I
Date 3'-.3`.� / Applicant 7�//r ��->»/+/�"--�f'vV/ WATER CLOSET NEAREST /nT
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. V
COMPENSATION INSURANCE OWNER
(This section need not be completed if she work involved by SHOWERjltuh()
she permit is for one hundred dollars ($100)or less.) LAVATORY MAL
ADDRESS
I certify that in the performance of the work for whichthis
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER L\
CONTRACTOR IJ
Date Applicant " CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 1//)l
Exemption, you should became subject to 'the Workers' SWIMMING POOL RECEPTOR
�(� LN q
Compensation proCITY TEL. NO.visions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE \\'� LIC.
deemed revoked. WATER HEATER LICENSE NO. i CLASS _ C
LICENSED CONTRACTORS DECLARATION GAS SYSTEM OUTLETS O DISTRICT NO. P ESSED BY
I hereby affirm that am licensed under provisions of Chapter 9 5.
/(
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER (l
and Professions Cade,and my license is in full force and effect. 5 PER SYSTEM FINAL VALI TION
License Number /cV,7Lic. Class C_,40 C-3�. DAT O
/
BY
Contractor? ��
7rr�n�./ I^/u'r Date� '2 "S/� - �/ '� O
❑ 1 am exempt under Sec. 0
B.&P.C. for this reason LU
Plan check fee (L
Date: N
PLUMBING PERMIT ISSUING FEE$ / z
Signature _
' - TOTAL FEE• ;R 6 6 1.3 qAq
FAMILY Plan check applicant q,9 flit a.5 H
'SINGLE
HOME OWNER-BUILDER DECLARATION Name e e e1 6 5,0 csi
I hereby affirm that I am exempt from the Contractor's License Address-Low for the following reason (Section 7031.5, Business and 0 3.03-87
Professions Code): City Tel. No.
❑ 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. G): _
Lender's Nome
tender'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-mentione prwt f coon purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ig azure of. ermine Date