HomeMy Public PortalAbout9674 LAS TUNAS DR_Plumbing__ WORKERS'COMPENSATION DECLARATION 81 w APPLICATION FOR PLUMBING PERMIT
I l�Preby,affirm that I have a CE certificate of consent to self e� e» (z-ao)
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
COUNTY OS ANGELES /� BUILDING AND SAFETY
Policy No. Company / ( `
D Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) VUILDING
• ADDRESS
Certified co r
py is filed with the county building inspection NUMBER FIXTURE OR ITEM FEE
department. LOCALITY
WATER CLOSET
Date Applicant z NEAREST 01
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved LAVATORY MAIL
ADDRESS A
by the permit is for one hundred dollars ($100) or less.) SINK OU CITY TEL.NO.
I certify that in the performance of the work for which this DISHWASHER
permit is issued, I shall not employ any person in any manner CONTRACTOR ! , O
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER F—
ADDRESS U
Date&64ek Applicant
SWIMMING POOL RECEPTOR O_
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL. NO. to
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. Z
Compensation provisions of the Labor Code, you must forth- WATER HEATER LICENSE NO. CLASS
with comply with such provisions or this permit shall be
deemed revoked. / DISTRICT NO. P CESSED B
GAS SYSTEM OUTLETS
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL ? . ( VALIDATION
ness and Professions Code, and my license is in full force and DATE '�"
effect.
FINAL
License Numbed Lic.Class IC',71C BY
Contractor Date l6�
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE
Lic.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Address
License Law for the following reason (Section 7031.5, Busi- City Tel.No.
ness and Professions Code):
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project
(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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes.
Or ature&f Permittee Dafte