HomeMy Public PortalAbout9178 JAYLEE DR_Plumbing_8/16/1984_fixtures WORKERS' COMPENSATION DECLARATION /p\PPUCAMH FOR PLU p �MI (�E MP7
I hereby affirm that I have a certificate of consent to self 76A667A u V uU uvu u v�✓ u �uvu
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 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 ', I t
° v C
LOCALITY o
WATER CLOSET
Date Appl icani NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. _
COMPENSATION INSURANCE OWNER �^
(This section need not be completed if the'work involved by SHOWER /
the permit is for one hundred dollars($100)or less') LAVATORY MAIL �- /,
ADDRESS
I certify that in the performance of the work for which this
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permit is issued, I shall not employ any person in any manner SINK Q � TEL. NO.
so as to become subject to the Workers Compensation Laws. DISHWASHER
�j /�pp .��. �))�,rrrr,� CONTRACTOR
Date // Applican CLOTHES WASHER'
NOTIC6VfO A LICANT: If, afte making this Ce i icate of ADDRESS
Exemption, you should beco a subject to th orkers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL. NO.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE `s LIC.
deemed revoked. WATER HEATER �A� LICENSE NO. ^,CLASS
LICENSED CONTRACTORS DECLARATION DISTRICLWO. PR ED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS _�-�' �-•f
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER.
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL A (�
DATE /'—G 0
License Number Lic. Class
FINAL
Contractor Date BY f
I am exempt under Sec. �
B.&P.C. for this reason
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$'
Signature v :�'•3 5,4,b.A
TOTAL FEE
Plan check applicant
SINGLE FAMILY 2.0 0 2 2 5 0
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's LicenseAddress 2 2 5 Q 6
Law for the following reason (Section 7031.5, Business and I
Professions Code):HPI City Tel. No. t 1 -67.8 4
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.).
Lend'er's Name
Lender's Address
I certify that I have read this application and state that the D
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
above-mentioned property for inspection purposes.
c SEE REVERSE FOR EXPLANATORY LANGUAGE
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ignature of PerriTitt I DcAe