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WORKERS'COMPENSATION DECLARAk,ION 76we67w 'APPLICATION
AppLICAT0ON FOR PLUMBING pERtilIT
I hereby, affirm that I have a certificate :)f consent to self; ce eta (2-80)
insure, or,a•certificate of Workers'Compensation Insurance,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 O'R TYPE) BUILDING "
ADDRESS
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM O FEE
department. WATER CLOSET rte. LOCALITY 1
Date' Applicant NEAREST
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER / OWNER .
LAVATORY _ MAIL
A }
(This section need not be completed if the work involved DDRESS a
by the permit is for one hundred dollars ($100) or less.) SINK
CITY TEL. NO. U
I certify that in the performance of the work for which this DISHWASHERCONTRACTOR cci
permit is issued, I shall not em loy any person in any manner 0
so as "come subject to t WCkKer ' C pensat to Laws. CLOTHES WASHER ADDRESSW Atli, U
DatE�� \\V Applicant \\ tL
,I ` SWIMMING POOL RECEPTOR d
NOTICE O APPLICANT: If, after maki this Certificate of CITY TEL. NO � N
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC.
Compensation provisions of the Labor Code, you must forth- LICENSE NO. CLASS
with .comply with such•provisions or this permit shall be WATER HEATER
deemed revoked. DISTRICT NO. PRO ESSED BY
GAS SYSTEM OUTLETS
LICENSED CONTRACTORS DECLARATION OUTLETS OVER Z—, G e
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL VALIDATION
ness and Professions Code, and my license is in full force and DATE j
effect.
FINAL
License Number
`� Lic.Class BY
Contractor ti Date
lam exempt from the licensing requirements as I am a Plan check fee f
licensed architect or a registered professional engineer
PLUMBING PERMIT ISSUING FEE$
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):
MI, as owner of the property, am exclusively contracting z U 7 �.3 A
with licensed contractors to construct the project
(Section 7044,Business and Professions Code). # o o 0 0 o.5
CONSTRUCTION LENDING AGENCY .2- 0.2 8,'5 O..
I hereby affirm that there is .a construction lending agency
for the performance of the work for which this permit is .0 0 0 2 8.5 0
issued(Sec. 3097,Civ.C.).
Lender's Name "0 7.0 1 —8.2
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
i%ove-mentio ed perty or inspection pposes.
:Z_
Ng�n.ture XPermittee Dat