HomeMy Public PortalAbout5710 KAUFFMAN AVE_Plumbing__ WORKER�'.COMPENSATION DEtLARATIOt� APL Ar� N FOR o�L6 J IT
' I hereby.offirTri shat I have a certificate of consent to self 76A667A
insure?, or a certificate of Workers' Comaensation Insurance, CE 817(REV. 10/81)
or a Certifie co thereof (Sec. 38006b c.) t COUNTY OF LOS ANGELES/ ( BUILDING AND SAFETY
Policy No. (/�/�-7 Compa ,
Poln
Certified copy is hereby furni hed.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with t e count building inspec- ADDRESS
on epartment. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Dat Ake, Applica WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' c;2, BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER
} i
(This section need not be completed if the work involved by SHOWERMAIL f
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRES ^�
I certify that in the performance of the work for which this /J
permit is issued, I shall not employ any person in any manner SINK 1550 CITY ZZ � TEL. NO >�
so as to become subject to the Workers'Compensation Laws. DISHWASHERJ
1'�u CONTRACTOR
Date Applicant CLOTHES WASHER Q6 ADDRESS //�jj
NOTICE.TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR /�LGL/ ,fes
Exemption, you should become subject to the Workers' o
Compensation provisions of the Labor Code, you must forth- CITY
LAWN SPRINKLER SYSTEM 54
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. P SED BY
1 hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 7 2 cR�
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER &
and Professions Code,and my license is in full force an ffect. 5 PER SYSTEM FINAL BALI TI®N @'
DATE 0
License Numb e— Lic. Class
FIN�- AL O
Contractor � Date BY r� �
I am exempt under Sec. I�
B.BP.C. for this reason
Plan check fee g
Date:
PLUMBING PERMIT ISSUING FEE$ d
Signature -'
TOTAL FEE
SINGLE FAMILY "'—
Plan check applicant �s
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
Professions Code): City Tel. No. ° - 94,50
❑ I, as owner of the property, will do the work and the
00 $19P
po (j _
structure is not intended or offered for sale (Section 0 4 0 — J
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 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-me . ned property for inspection purposes.
`2 SEE {3ENEt35E OO14 EXPLANATORY LANGUAGE
Signature of Permittee Date