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WORKERS'COMPENSATIONDECLARATION 1e•681A A.PPLICA�TION FOR PLUMBING PERMIT
I hereby affirm that I have i certificate of consent to self ce en ji-eol
insure, or a certificate of Workers'Compensation Insurance,or .
a certified copy thereof(Sec. 3800,Lab.C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑ Certified copy is hereby furnished. 'FOR APPLICANT TO FILL IN (PRINT OR TYPE) WILDING s
ADDRESS /L. g N t4.q U. .
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM 0 FEE
department. —� LOCALITY e�q�
WATER CLOSET
Date Applicant NEAREST 1
BATHTUB C SS ST. (Qf. rs
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER WNER
A ,J y
(This section need not be completed if the work involved LAVATORY MAIL
ADDRESS & L g1GI N(R4 ✓ 0�- CL
by the permit is for one hundred dollars ($100) or less.) w
SINK ITVmoi! I�{' Cv TEL. NO.a,�>^'h3
I certify that in the performance of the work for which this DISHWASHERG cc
permit is issued. I shall not employ any person in any manner CONTRACTOR O
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER ADDRESS U
Date Applicant Lu
SWIMMING POOL RECEPTOR d
NOTICE TO APPLICANT:If, after making this Certificate of CITY TEL.NO. to
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. Z
Compensation provisions of the Labor Code, you must forth- WATER HEATER LICENSE NO. CLASS
with comply with such provisions or this permit shall be
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. PRO ESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER Q
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL �/_G�✓� VALIDATION
ness and Professions Code, and my license is in full force and DATE CT/
effect.
FINAL
License Number Lic.Class BY
Contractor Date
ElI am exempt from the licensing requirements as 1 am a Plan Check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051. Bus-
iness and Professions Code). TOTAL FEE
Lie.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Address
:9.4 9 33 A
License Law for the following reason (Section 7031.5, Busi- City Tel.No. r
ness and Professions Code): _ 4 e•e e o e 5
Ell, as owner of the property, am exclusively contracting
with licensed contractors to construct the project 2'-.0 4 a.5 0
(Section 7044,Business and Professions Code).
>'a 4fl5060
CONSTRUCTION LENDING AGENCYr
I hereby affirm that there is a construction lending agency 07. 1 3f-82
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
author epresentatives of this County to enter upon the
above- en tone propert or inspectionpprpose
i ature of Permittee battT