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WORKERS'COMPENSATION DECLARATION ' APPLICAT9ON 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, Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company ,
❑ Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
El /%L? A p
Certified copy is filed with the county building inspec- ADDRESS �j J [ (1 y7(J
tion department NUMBER FIXTURE OR ITEM @ FEE LOCALITY �� R
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER OWNER 1
(This section need not be completed if the work involved by
the permit is for one hundred dollars($100)or less.) LAVATORY MAIL
✓tel L
I certify that ih the performance of the work for which this ADDRESS
permit is iss ed, I shall not employ any person in any manner SINK .� CITY TEL NO
so as to be me suble t to the Workers'Compensation Laws DISHWASHER
00, CONTRACTOR
Date / Applicant i CLOTHES WASHER
NOTI TO APPLI ANT I� ter making this Certificate of ADDRESSlz�
Exemptionyou should become subject to the Workers' SWIMMING POOL RECEPTORCompensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY L f TEL NO '
with comply with such provisions or this permit shall be STATE !, LIC d
deemed revoked WATER HEATER LICENSE NO 3 .2 CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO oPROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER 5t L
and Professions Code,and my license is in full force and effect 5 PER SYSTEM FINAL
DATE VALI TION
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License Number r Lic Class `�
y� j / FINA O
/
Contractor / r f yLye Date �( BY �` V
I am exempt under Sec
F-1
B &P C for this reason l! s Zf
` Plan check fee
Dar
PLUMBING PERMIT ISSUING FEE$
S+gnat 15-0
TOTAL FEE 5 ; ,o o 4 Q,5 Q'
Plan check applicant 1-;
SINGLE FAMILY i o 0 ar �+
HOME OWNER-BUILDER DECLARATION Name 0.
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
❑ I, as owner of the property, will do the work and the
structure is 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 jaws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned pro5prty for inspection pure es
Signa�tureof
SEE REVERSE FOR EXPLANATORY LANGUAGE
— Permittee 'v� to