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WO;';ERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I�hc{e��%r•�Pby offiQ thou I lhave a certificate of consent to self 76A667A
w 7fi5171�c;,`or a ce,lificate of-Workers' Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES ..BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished.❑ BUILDING Q FOR APPLICANT TO FILL IN(PRINT OR TYPE)
Certified copy is filed with the county building inspec- ADDRESS
NUMBER FIXTURE OR ITEM � FEE
tion department. LOCALITY
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' ,Z. BATH TUB ') Jl CROSS ST. �—�V7�
COMPENSATION INSURANCE SHOWER V}1 OWNER F��N{� T � VA'�l rR
(This section need not be completed if the work involved by (/ MAIL', Q '/'
the permit is for one hundred dollars ($100)or less.) LAVATORY Q� ADDRESS /�T�- ErE � ���
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner a SINK 60 CITY' SA41 E�a�, c. TEL. NO. ZL9s-7/6p
so as to become subject to the Workers'Compensation Laws. DISHWASHER
� � ® CONTRACTOR
Date U Applican r`"'�^" r CLOTHES WASHER Al p
NOTICE TO APPLICANT: If aftmaking this Certificate of ADDRESS
Exemption, you should berecome subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL. NO.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER b
(J4/171 LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION � DISTRICT NO.� P CESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
DATE V VALI TION
License Number Lic. Class 0_,
FINAL 1 U
Contractor Date BY Y 4
0
❑ I am exempt under Sec. 0
B.BP.C. for this reason j
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ Z
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name 5l4AfE A5 -21,/A459— - ;9 6 8 Q 9 A
I hereby affirm that I am exempt from the Contractor's License # a o o a a 5
Law for the following reason (Section 7031.5, Business and Address
Professions City Tel. No.
Code): I o 10650
I, as owner of the property, will do the work and the o o 1 0 6 5 6
structure is not intended or offered for sale (Section ® 04,06-8 7
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby offirm 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 ►
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.
SEE REVERSE FOR-EXPLANATORY-LANGUAGE
i-f-a
Signature Perm ttee IF Date