HomeMy Public PortalAbout6003 HART AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION AP UCAVIOO N FOR P LUM o Nr, nk9V r
I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 • �j
insure, or a certificate of Workers' Compensation Insurance, 76A667A ILII
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT:70F PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished.
17FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
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' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER
SHOWER
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL
MAILADDS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
,
p y I CITY TEL. NO.
Compensation provisions of the Labor Code, you-must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed undei provisions of Chapter 9 �� GAS SYSTEM OUTLETS �D p
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER O
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
VALIDATION
DATE d
License Number Lic. Class
FINAL U.
Contractor Date BY (/
❑ I am exempt under Sec.
B.&P.C. for this reason Plan check fee Fo fn;
Date:
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE Q
Plan check applica t
SINGLE FAMILY '�
HOME OWNER-BUILDER DECLARATION Name -.�.r
f� . Fe;� 1 c 7
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
ro ssions Code): City ov, C Tel. No.
I, as owner of the property, will do the work and the -'
structufe is not intended or offered for sale (Section `( i
» )
7044, Business and Professions Code). ;_ — `• `"'""'"
CONSTRUCTION LENDING AGENCY
I hereby"affirm that there is a construction lending agency for -;fit w.r. a I.! {
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
- 7;3t t!i••-t'i t%i'.t. ai.i'�t;±'r
Lender's Name
Lender's Address c`: J.
I certify that I have read tliis 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 repres ntativ s of this County to enter upon the
ove-mentignpro r for inspection pu oses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
igna ure f Peei� I Date