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}� tWORKERS' COMPENSATION DECLARATION 20-0026 DPW 4/90 APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consent to self in- 76A667A
sure,or a certificate of Workers'Compensation Insurance,or a
certified copy thereof (Sec. 3800, Lob. 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 t/
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY L/ ?
Date Applicant WATER CLOSET(TOILET) NEAREST f /
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. (/J •�/e,�/j
COMPENSATION INSURANCE SHOWER OWNER �L4 0 +
(This section need not be completed if the work involved by MAIL , �l
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS �L W L�` "vo //
I certify that in the performance of the work for which this per- SINK ^ n o p
mit is issued, I shall not employ any person in any manner so CITY TEL. NO.e � ZjL e>' y��
as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR � �
Date. Applicant CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. / WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS0�
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
fect. HOSE BIB DATE _
License Number Lic. Class
FINAL O
Contractor Date BY V
O.
ElI am exempt under Sec.
B.BP.C. for this reason Plan check fee
►.
Date: PLUMBING PERMIT ISSUING FEE$ d
Signature TOTAL FEE
SINGLE FAMILY s
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name 3,3Ci`
Low for the following reason (Section 7031.5, Business and
Professions Code): Address I ITEMS-
1, as
•fI,'as owner of the property, will do the work and the City Tel. No. 3
structure is not intended or offered for sale(Section 7044, i
-c
Business and Professions Code). ► i- r = '
yl•(('j1'J�7j�
CONSTRUCTION LENDING AGENCY
k
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.).
`Y i15.
Lender's Name
Lender'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-mentioned property for inspection purposes.
c t SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date