HomeMy Public PortalAbout9031 EMPEROR AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I herby,affrrm that C have a certificate of consent to self 76A667A
insure, or a certificate of Workers' Compensation Insurance, CE 817(REV 8/86) �J
or a certified copy thereof (Sec 3800, Lab C )
Pohc o�3C�� ,5./}� �� COUNTY OF LOS ANGELES' DEPT OF PUBLIC WORKS _
ompany14 111
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 @ FEE LOCALITY
�
WATER CLOSET �-`5q&,Z/
Do Appli4ant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST _
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less ) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL NO
so as to become subject to the Workers'Compensation Laws DISHWASHER
CONTRACTOR -
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If, after making this Certificate of SWIMMING'POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL NO
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with 'such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER ,LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO P OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER I
and Professions Code,and my license is in full force and effect 5 PER SYSTEM FINAL VALI ATION
O
DATE
4�
License Number Lic Class
FINAL 0
Contractor Date BY A
❑ I am exempt under Sec 7 7 8 3
B 8P C for this reason # 0 0 0 0 H
Plan check fee Z
Date PLUMBING PERMIT ISSUING FEE$
Signature =
TOTAL FEE 0 0 0 5
5 0
licant
' SINGLE FAMILY Plan check a PP �off � l) �2 7,�$7
HOME OWNER-BUILDER DECLARATION Name
I hereby afrm that I am exempt from the Contractor's License _
Law for the following reason (Section 7031 5, Business and Address g/
Professions Code) City /V. 6E Tel No icl/G✓��j
❑ 'I, as owner of the property, will do the work and the 0,� /'I�
structure is not intended or offered for sale (Section
7044, Business and Professions Code) # 3
CONSTRUCTION LENDING AGENCY , o 0 2&`5 OZ:
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued 3 _8 7
(Sec 3097, Civ C )
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
a�bfionecl property for inspection purposes '
SEE REVERSE FOR EXPLANATORY LANGUAGE
S'Ig-rAlture of Permitte Date