HomeMy Public PortalAbout5742 KAUFFMAN AVE_Plumbing__ '; WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I R�reby of}icm that I have a certificate of consent to self in- . 20-00276A66A DPW.4/87 /1
s6re,or a certificate of Workers'Compensation Insurance;or a CE 817(REV. 8/86) `SIL JAI
cert,f,Vd co�gy t/h/eQreof (Sec. 3800, Lab
Policy Not ' S`9Gs Compan COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS ,
` ❑ Certified-copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE)
Certified copy is filed with the ounty building inspection ADDRESS
d partment/� NUMBER FIXTURE OR ITEM @ FEE LOCALITY
JV
_ 7 Applicant WATER CLOSET(TOILET) e
Date NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' —2— BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER S•�,.
(This section need not be completed if the work involved by MAIL. /' �s
the permit is for one hundred dollars ($100)or less.) LAVATORY Q ADDRES U
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so SINK p ,: CITY
as to become subject to the Workers' Compensation Laws. DISHWASHER 7 d CONTRACT
!ol-
Date Applicant CLOTHES WASHER Q ADDRES
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY ////i��%d77iu� T `7 7 ?`� 7 7
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE G p p LIC.
ed. WATER HEATER LICENSE NO. CLASS
GAS SYSTEM OUTLETS �o
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ,Pl/r/SED BY
I hereby affirm that I am licensed under provisions of Chapter /
9(commencing with Section 7000)of Division 3 of the Business / OUTLETS OVER (/ O
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL ` VALIDATION
a / DATE C �,
IL
License mb.1 < �7 Lic. Class` `3, t O
/ FINAL V
cc
Controcto Datf�' �/'�/ BY O
OI am exempt under Sec.
B.&P.C. for this reason , g
Plan check fee -
Date: PLUMBING PERMIT ISSUING FEE$ 3 G
Signature' TOTAL FEE Od
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant _
I hereby affirm that I am exempt from the Contractor's License Name -
Law for the following reason (Section 7031.5, Business and
Alm r
Professions Code): Address
I,' as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). PITA
'
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Poo
CONSTRUCTION LENDING AGENCY -,•- --
I hereby affirm that there is a construction lending agency for H��'�`
the performance of the work for which this permit is issued, C•ti-`•
(Sec. 3097, Civ. C.). s sNz+_L
Lender's Name
t11 ' tY
Lender's Address -
9 Sr' �:
c 1 t,>.,
I certify that I haves 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
a thorize representatives of this County to enter upon the
ve do e property for inspection purposes.
3_ _ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date