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y)-'WORKERS'it COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
hereby affirm that I have a certificate of consent to self 76A667A
insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof (Sec. 3800, Lob.
C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
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Company ,01"T_
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS 00FIEVAAVE
,
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY ` G
WATER CLOSET ^
Date Applicant ITY CA
NEAREST e
CERTIFICATE OF EXEMPTION FRO CROSS ST. Lbhu ORKERS' BATH TUB r P��. 90•
COMPENSATION INSURANCE OWNER 1N f k�
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars ($100)or less.) LAVATORY / MAIL
I certify that in the performance of the work for which this ADDRESS
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER "TH/�
CONTRACTOR / IrnL
Date Applicant ADDRESS
CLOTHES WASHER 3If� Aw .
NOTICE TO APPLICANT: If, after making this Certificate of
a !
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY r s e; -Co�� TEL. NO. ld—ofS
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM �s��
STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. 3 CLASS A-1
LICENSED CONTRACTORS DECLARATION, 7—Dismc 7—Disc �. PROC SED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 1 �)
(commencing with Section 7000 of Division 3 of the Business c V
( 9 ) OUTLETS OVER �
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM DATE VALIDA ION
3 v
License Number Lic. Class NJ
FINAL
Contractor Date 2.9 Zfs BY
❑ I am exempt u er Sec. 91 9 2 9:A
# 000005
B.BP.C. for this reasono 0
Plan check fee I 4 0.5 0= g
Date: PLUMBING PERMIT ISSUING FEE$ ® 0 4291-99 U'
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
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. 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 rep esentatives of this County to enter upon the
above-mensed prop ty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date