HomeMy Public PortalAbout6119 OAK AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION 76AS67A
hereby affirm that I have w certificate of consent to self cE e17(z-ea) APPLICATION FOR PLUMBING PERMIT
sure,or a certificate of Workers'Compensation Insurance,or
certified copy thereof(Sec.3800,Lab.C.)
COUNTY OF LOS ANGELES Tdd BUILDING AND SAFETY
olicy No. Company
13 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS n,
R
Certified copy is filed with the county building NUMBER FIXTURE OR ITEM • FEE
p g inspection
department. LOCALITY
Date Applicant WATER CLOSET NEAREST
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER
LAVATORY MAIL ' D
(This section need not be completed if the work involved LAADDRESS V �
by the permit is for one hundred dollars ($100) or less.) SINK
CITY le tl TEL.NO.2_W6_1qS8
CLO
I certify that in the performance of the work for which this DISHWASHER U
permit is issued, I shall not employ any person in any manner CONTRACTOR
so as t b o e subject to the Wcxker_s'Com on Laws. CLOTHES WASHER 0
►Il/i/ .rs'C ADDRESS O
Date �' Applicant Dim H
SWIMMING POOL RECEPTOR U
NOTIC TO APPLICANT: If, after making this Certificate of CITY TEL.NO. LL
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. N
Compensation provisions of the Labor Code, you must forth- WATER HEATER LICENSE NO. CLASS
with comply with such provisions or this permit shall be —
with
d revoked. GAS SYSTEM OUTLETS DISTRICTNO
LICENSED CONTRACTORS DECLARATION OUTLETS OVER •V
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL VALIDATION
ness and Professions Code, and my license is in full force and DATE
effect.
FINAL
License Number Lic.Class BY
Contractor Date
I am exempt from the licensing requirements as I am a Plan Check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ a
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 e^ S
I hereby affirm that I am exempt from the Contractor's Address M Q / L
License Law for the following reason (Section 7031.5, Busi- City Tel.No. J?6
ness and Professions Code):
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the projecta c r
(Section 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY o 1
I hereby affirm that there is a construction lending agency r c 1
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- entioned property for inspection purposes.
Signature of Permittee Date