HomeMy Public PortalAbout5843 KAUFFMAN AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
�.insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof (Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished. BUILDING
F-1 �
FOR APPLICANT TO FILL IN(PRINT OR TYPE)
Certified copy is filed with the county building inspec- ADDRESS 9 1-13 AJ, ��'f1-0.--F,01NJ
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY `� MSL E �� f
Date Applicant WATER CLOSET NEAREST �
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER ��r g .1 /2#_7 49t>+
(This section need not be completed if the work involved by MAIL Q
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS �CJ
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY r A L�^ C` TEL. NO,
so as to become subject to the Workers'Compensation Laws. DISHWASHER C�
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITYe7yU "�6 TEL. NOq��SGC�d
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATELIC.
deemed revoked. WATER HEATER LICENSE NO3 40&4/S CLASS SC-efyc3C—
LICENSED CONTRACTORS DECLARATION DISTRICT NO. P ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS =i_'
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER t J y
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL � VALIDATION �
License Numbe3 +M7�-5 Lic. Class5C L/VL'3� ���•�•� DATE S' V
FINAL 99
O
Contractor Date BY b
I am exempt under Sec. �
B.&P.C. for this reason
Plan check fee ® �
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name '` - I', A
I hereby affirm that I am exempt from the Contractor's License
Law
";: o c; c o c Jr
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. 2 ° o 3 0 5 0
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section c `' " 3 0.6 0 v
7044, Business and Professions Code). POP
0.7;�'U _ 3
CONSTRUCTION LENDING AGENCY
1 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 th_A_ddress
ify
I certat 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 u on the
above-men tione property fo inspection pur ses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
SigrOrure of Fermittee D to