HomeMy Public PortalAbout5025 KAUFFMAN AVE_Plumbing__ WORKERS' COPAPENSATtJN DECLARATION /p1 ppUCAIMN FOR PLL p �M�(? PERNT
I hereby affirm that`( have a`certificate of consent to self 76A667A u V ti uvu u V v uvu
winsure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) �—
&yt 5 c ther,eAf (Sec 3800, La C.) .. COUNTY OF LOS ANGELES J �� BUILDING AND SAFETY
'Policy No. Company
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
512 'Certified copy is filed with the c my building inspec- ADDRESS S "
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
n
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM RKERS' BATH TUB CROSS 5T. .
COMPENSATION INSURANCE OWNER
(This sectionneed not be completed if the work involved by SHOWER MAIL r -
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS tS�!y97
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY - TEL. NO _ S
so as to become subject to the Workers Compensation Laws. DISHWASHER
CONTRACTORSS
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT- If, after making this Certificate of ADDRESS 'r 7
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY TEL. NO.
Compensation provisions of the Labor Code, you.must forth- LAWN SPRINKLER SYSTEM S1.9r 7
with comply with such provisions or this permit shall be STATELIC.
deemed revoked. WATER HEATER LICENSE NO. J O� CLASS �> d
LICENSED CONTRACTORS DECLARATION DISTRICT ROCE4SED BY
I hereby affirm That I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS I i
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER "(J
and Professions Code, and my license is in full force and effect: 5 PER SYSTEM FINAL
VALIDATION O
License Number3ft! Lic. Class � DATE V
�,,y� `/I q FINAL 7 O
Controcto � Date d�� BY
S dA_' .
V
❑ I am exempt under Sec.
/G 11-3
B.BP.C. for this reason 'Plan check fee D
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant 9 GO 3J,9 A
HOME OWNER-BUILDER DECLARATION Name c'0 0 0 0 5
1 hereby affirm that I am exempt from the Contractor's License Address
Low 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 �l0 3 0,5 C gym'•
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.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above mation is correct. I agree to comply with all County
ordin nces and State laws regulating Plumbing, and hereby
outhcfize representatives of this County to enter upon the
abo -mentio d,property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
bi,griature o ermittee Date