HomeMy Public PortalAbout9180 JAYLEE DR_Plumbing_1/14/1985_gas syst WORKERS'COMPENSATION DEC�LARATIGN �pp�p�Q�p�� FOR PLUMENG NG PERMU
14�ereby atfirm th'a^ I have a certificate o'f coo"sent, to self 76A667A x
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. BUILDING T
ElADDRESS APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM . @ FEE LOCALITY
Date Applicant WATER CLOSET NEAREST -
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST. p W7&
COMPENSATION INSURANCE SHOWER OWNER R.
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS (.
I certify that in the performance of the work for which this fi
permit is issued, I shall not employ any person in any manner SINK CITY epq LP G TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with.comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. P OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS Tom` ® /
�
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER �J
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL f,�� NALI A ION O
DATE`
License Number Lic. Class
FINAL O
Contractor Date BY �f
f❑ I am'exempt under Sec. - Z � 3�5 A IL
rA
B.&P.C. for this reason
Plan check fee D # o o o 0 0 5
Date: PLUMBING PERMIT ISSUING FEE$ (� ) 0 0 Jr O
Signature
TOTAL FEE
Plan check applicant 0 0 0 1 5 0 czi
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name 0 1, 1 4._8 5
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 D
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 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.
SEE REVERSE FOR EXPLANATORY LANGUAGE
to /-/o
Signature of Permittee Date