HomeMy Public PortalAbout9556 OLIVE ST_Plumbing__ WORKERS'COMPENSATION DECLARATION i it—•APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 176A667A
insure, or a certificate of Workers'Compensation Insurance, ICE 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. BUILDING
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS m
Certified copy is filed with the county building inspec- NUMBER FIXTURE OR ITEM
tion department. ( ® FEE LOCALITY
Date Applicant WATER CLOSETAr
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB / CROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars($100)or less.) LAVATORY MAIL
ADDRESS
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
SINK CITY TEL.NO.
so as to become subject to the Workers'Compensation Laws. > DISHWASHER
C /J�/� CONTRACTOR fJ
Date o
—7-943 Applicant�9&j CLOTHES WASHER `� ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 12 0 w SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY Q TE
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. ! WATER HEATER LICENSE NOZ ZOQ CLASS —=346
LICENSED CONTRACTORS DECLARATION DISTRICT :7-PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �'
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER '
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
DATE r 1 VALIDATION
License Num erLic. ClassC-3 F 09
o 1. FINAL ' p" o
Contracto Q Date BY
I am exempt under Sec. �
B.BP.C. for this reason
�^ S3 ,, Plan check fee ► `�r
Date:
(, PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Licse Address
Law for the following reason (Section 7031.5, Businesen
s and j AProfessions Code): City Tel. No.
❑ 1, as owner of the property, will do the work and the I; i, 0 0 0 0
structure is not intended or offered for sale (Section lop7044, Business and Professions Code). r
J
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 ( n. _ .•
(Sec. 3097, Civ. C.). "
Lender's Name
Lender's Address
I certify that I have read this application and state that the j ►
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
a ent:ioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
I