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-1ffirKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT
20-0026 DPW 4/87
,,.Nhereby, dffirm that I have a certificate of consent to self in 7,6A667A
sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV.8/86)
certified coq thereof(Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy Nd. Company
Certified copy is hereby furnished.
r-1FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS 3
department. !,: NUMBER FIXTURE OR ITEM @ FEE LOCALITY I r
Date A licant WATER CLOSET(TOILET) IZ
PP NEAREST �
CERTIFICATE.OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER M mb o
(This section need not be completed if the%fork Involved by
MAIL
the permit is for one hundred dollars(;100)or less.) LAVATORY ADDRESS 5 �
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CITY TEL. NO.
as to become subject to the Workers'Compensation Laws. DISHWASHER
t` CONTRACTOR
Date- ZZ� Applicant�V{`b St CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex-. SWIMMING POOL RECEPTOR414
emption,you should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
fed,Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION a
DATE l4W O
License Number Lic. Class f r V
� 00 FINAL
Contractor Date G1 i BY O
F1 I am exempt under Sec. �t W
B.&P.C. for this reason cc
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature TOTAL FEE
SINGLE.FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name c 9 oil.b A
Law for the following reason (Section 7031.5, Business and
Professions Code): Address # 0 0 0 o o 5
�I, as owner of the property, will do the work and the City Tel..No. I 0 -1 6 5 0
structure is not intended or offered for sale(Section 7044, o o o 1 6 5 o xu
Business and Professions Code).
CONSTRUCTION LENDING AGENCY 0 2 2 2-8 8
1 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 statethat the
above information is correct. I agree to comply,with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives f this County to enter upon the
abov ntioned proper for inspection purposes.
' z-z.7r-0(_0 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date