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WORKERS'COMPENSATION DECLARATION APPUCAMN FOR PLUI'IVl1ENG PERNT
I'hereb' affirm that 1 have a certificate of consent to self 20-0026 DPW 6/87
,insure, or a certificate,of Workers' Compensation Insurance, 76A667A
`or-a certifiecfcopy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Pol'e "5N Company 5j})'� �—UA� ^
Ky No.Certified copy is hereby furnished. BUILDING
17FOR APPLICANT TO FILL IN(PRINT OR TYPE), ADDRESS
Certified copy is filed with e county buildi g inspec-
tion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY .�/� �� TY
^•
WATER CLOSET
Date 6 4-- Applicant :5 NEAREST n /�
CERTIFICATE OF fXEMPTlO
BATH TUB CROSS ST. v! Ey
-- � -
COMPENSATION INSURANCE SHOWER OWNER VJ e)
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS _ 41
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY rte L�� 7 '�,. TEL. NO. 7S
so as to become subject to the Workers Compensation Laws. R DISHWASHE
I CONTRACTOR SF
Date Applicant l' CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate ofADDRESS
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL. NO.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter.9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM• FINAL VALIDATION
License Number 913 71-5 Lic. Class 3 DATE Z—( � —Cl 3 0
v.
FINAL �
Contractor � � kl Date �/ �— BY 0,
❑. 1 am exempt under Sec.
W,
B.&P.C. fort is reason 12
Plan check fee
ate: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL"FEE
Plan check applicant
SINGLE FAMILY s
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License
Law f r the following reason (Section 7031..5, Business and
Address
P of ssions 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 t-,• q;
I hereby affirm that there is a construction lending agency for CHAN -
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 stole 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
above-mentioned'property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
tj 6 -6 - v
SignaturY of Permittee Date