HomeMy Public PortalAbout5946 KAUFFMAN AVE_Plumbing__ WORKERS'COMPENSAION DECLARATION ®®®�I� �� PLUMBING ®ER�'�'
! hereby affirm that I have a certificate of consent to self 76A667A A t+ !B ee RM
i_4u+'eor a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof (Sec. 3800, Lab. C.No COUNTY OF LOS ANGELES BUILDINP AND SAFETY
Pol
,icy No. !! Company 11 31, 31
Certified copy is hereby furnished. BUILDING r� 9
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADD ES 7 Y<
Certified copy is filed with the county building tinspec-
tion oriment. 1` NUMBER FIXTURE OR ITEM @ FEE r�,y y 7
9 c ! 1 a LOCALITY �Y�'1! 6_C�
Dater i Applicant "` x_ /�'� WATER CLOSET NEAREST
9
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. / �S . (y„ i.'�3 t` L
/ COMPENSATION INSURANCESHOWER
OWNER
(This section need not be completed.if the work involved by MADDRESSAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY yw"�R� j r ire s t
.Z� / f /e I(`-�• � �� /��'•�9.Z P
I certify that in the performance of the work for which this �j
permit is issued, I shall not employ any person in any manner SINK CITY g� � j, /7 TEL. NO.�� t{ Y
so as to become subject to the Workers'Compensation Laws. DISHWASHER y Y ^
CONTRACTOR 101
Date Applicant CLOTHES WASHER i
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS , , ��P Jtfi,q A;n
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR y
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY .r� 14, rn TEL. NO. �5
with comply with such .provisions or this permit shall be STATE '�'� y� /
deemed revoked. WATER HEATER LICENSE NO. /'f J 2 �� CLASS
LICENSED CONTRACTORS DECLARATION I -RICTNO. FJZQCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL V LIDATION
License Number - 62D A T E
I—Lic. Class
FIN
Contractor .t �i , � t 9:-� Date ;2 ?L BY
❑ I am exempt under Sec.
B.BP.C. for this reason Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$ /O �0 � �p
Signature f
TOTAL FEE ✓
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
1 hereby affirm that I am exempt from the Contractor's License Address /r
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
structureis 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 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
Signature of Permittee Date