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WbRKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers'Compensation Insurance, 76A667A "
or a cert'if'ied tbpy thereof Sec. 38"b: C.) COUNTY OF LOS ANGELES DEPT..OF PUBLIC WORKS
Policy No pony/IY1.yr 16Q-,47-71
1 ca, •
E) Certifiedcopy is hereby furnished. O ,47 7/
FOR APPLICANT TO FILL IN(PRINT OR TAPE), BUILDING
❑' Certified copy is filed with the county building Inspec- ADDRESS C•
' do depar ment. NUMBER FIXTURE OR ITEM FEE LOCALITY
Date Appli4ant WATER CLOSET I-Sf7 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB DD CROSS S7.
COMPENSATION INSURANCE OWNER
' QQl ry On
(This section need not be completed If the work Involved by � OV MAIL U
SHOWER �1•
the permit is For one hundred dollars($100)or less.) LAVATORY ADDRESS50
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person In any manner SINK CITY TA
NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR Plum
Date Applicant I CLOTHES WASHER ADDRESSIJ
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR i L�
Exemption, you should become subject to the Workers' CITY TEL.NO�
Compensation provisions of the Labor Code, you must:forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall 'be STATE LIC.
deemed revoked. '� WATER HEATER LICENSE NO.' CLASS O� Jlt�
LICENSED CONTRACTORS DECLARATION DISTRICT NO.�j PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS- D
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER ��
and Professions Code,and my license is in full force and.�ffect. 5 PER SYSTEM FINAL VALIDATION
q5W .1 DATE 9
License Number Lic. Clas
FINAL
Contractor Date kgtq i BY
C
❑ I.am exempt under Sec. C
8.8P.C. for this reason L I -Plan Check fee ► Cr
Date. PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE � ®O
SINGLE FAMILY
Plan check applicant
5
HOME OWNER-BUILDER DECLARATION Name4 I.v
I hereby affirm that I am exempt from the Contractor's License P•
Law for the following reason (Section 7031.5, Business. and Address 5j,) r' 135.00Professions Code): City Tel. No.. 1 !TEM;
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section , TOTAL 135 @,00
7044,'Business and Professions Code).
CONSTRUCTION LENDING AGENCY CHECK 0135.W
I hereby off irm that there is a construction lending agency for CHANGE .01)
the performance of the work for which this permit is issued
(Sec. 3097,Civ. C..).
Lender's Name
�1i�IJ— Cl�1 /t / i
Lender's Address
717 ' 1 AM11:210
I certify that I have read this application and state that the ► '
above information is correct 11 agree to comply with all County
s ord' s,, d State law egulating Plumbing, and hereby
ut orize�epresentativ f this County to enter upon the
above-mentioned property or inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignatu o Perm' Date