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WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 20-0026 13PW 6/87
Insure, or a certificate of Workers'Compensation Insurance, 76A667A
ora-certified copy thereof(Sec. 3800, Lab. C.) •COUNTY OF LOS ANGELES DEPT,OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished. BUILDING
, FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy Is filed with the county-building inspec- NU ER FIXTURE OR ITEM FEE
I* depart n LOCAUTf
r G
Date Applicant WATER CLOSET O NEAREST
T. G `
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work Involved by SHOWER'
MAIL
the permit Is for one hundred dollars($100)or less.) LAVATORY D DDRESS.
(-certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner SINK CITY NO. f„
so as to become subject to the Workers'Compensation Laws. DISHWASHER O CONTRACTOR !v
Date Applicant CLOTHES WASHER ADDRESS �l
NOTICE.TO APPLICANT:. If, after making this Certificate of SWIMMING POOL RECEPTOR �• "�r Gr
Exemption,. you should become subject to the Workers' CITY 2n S TEL.NO
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER-SYSTEM
with comply with such provisions or this permit shall be STATEy LIC.
deemed revoked.
.WATER HEATER LICENSE NO. / CLASS "
LICENSED CONTRACTORS DECLARATION ffo
TRI NO ROCESSED.BY
I hereby affirm•that lam licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division of the Business OUTLETS OVER ^
and Professions.Code,and my license is in full force a d effect. 5 PER SYSTEM V FINAL
DATE V LIDATION
License Numb r �F/ Lic.Class
a FINAL
Contractor Date. O BY C
❑ lam exempt under Sec. t
Q�
BAP.C.for this reason ®°
Plan.:Check fee
Date: PLUMBING PERMIT ISSUING FEE$ '
Signature
TOTAL FEE I cphl 60 ,
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name �+.�
I hereby affirm that I am exempt from the Contractor's License Address ACCT.Av
Law for the following reason (Section 7031.5, Business and ? 90.(X1Professions Code): City Tel. No.
❑ I, as owner of the'property, will do the work and thePoo , 1 1T
structure-'is not intended or offered for sale (Section TOTAL 90.1130
0 o�0
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY C Ii 90.00
Thereby affirm that there is a construction lending agency for i c
the performance of the work for which-this permit is.issued
(Sec. 3097, Civ. C.).
Lender's.Name =O-MOI 9/ 6/$9
Lender's Address 1 AN110
I certify t �isc
d this application and state that the ►
ab nn ormationrecJe
to comply with all County
or antes and Swsg Plumbing, and herebyth a representativesounty to enter upon the
�bove-m tioned propertycti n purposes.
I SEE REVERSE FOR EXPLANATORY LANGUAGE
S1 Permittee Date