HomeMy Public PortalAbout4835 HELEO AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION APFILRCAT�ON FOR PLUMBING PERMIT
I 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, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy
cy No. Company
Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY / C ��
Date Applicant WATER CLOSET NEAREST a-
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. pQ �
COMPENSATION INSURANCEOWNER
SHOWER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY
I certify that in the performance of the work for which this ADDRESS
permit is issued, I shall not employ any person in any manner SINK CITY TEL. N07���
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- CITY TEL. NO.
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM
STATE LIC.
deemed revoked.
WATER HEATER LICENSE-NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRIg OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS v-
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM
FINAL VALIDATION
DATE '� "� ' 6J
License Number Lic. Class
FINAL
Contractor Date BYE#
❑ I am exempt under Sec.
c�a
B.&P.C. for this reason Plan check fee g
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant
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
Pr essions Code): City Tel. No.
I, as owner of the property, will do the work and the '= 2 7 0,S A
structure is not intended or offered for sale (Section
7044, Business and Professions Code). ;';: c 0 0 o 0 5
CONSTRUCTION LENDING AGENCY 2 6 0 (I.6 5 0
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued 0 0 0 It./� 5 0-2
(Sec. 3097, Civ. C.). q
04, 10-53
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 repreZ
i s of this ounty to enter upon the
bov -mentionrty for i ction purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
-/V P8-3
Signature of ermittee Date