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WOMCERS'COMPENSATION DECLARATION20-0026 DPW APPLICATION FOR PLUMBING PERMIT
1 hereby, a}Ilrm that I have•a certificate of consent to self In- 7A 4/90
sura,or a certificate of Workers'Compensation Insurance,or a
certified copy thereof (Sec 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORM
Policy Nb. Company
Certlfled copy Is hereby furnished.
FOR APPLtC1NT TO RLL IN(PRINT OR TYPE) ADSS
Certified copy Is filed with the county building Inspection ADDRESS
department. NUMBER FIXTURE OR IN FEE Lim
Ddte Applicant WATER CLOSET(TOILET) /!;7 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB Cly ST.
COMPENSATION INSURANCESabWER s OW ER
(This section need not be complom If the work Invohred by MAIL
the permit is for one hundred dollars(;100)or lea.) LAVATORY ADDRESS
I certify that In the performance of the work for which this SINIK Q /!
mit Is Issued, I shall not employ any person In any manner so CITY �'0
TEL r
as to become subject to the Workers'Compensation Laws. DISHWASHER
Date Applicant CLOTHES WASHER
ADDRE
NOTICE TO APPLICANT: If, after making this Certificate Ex- SS
amption,you should become subject to the Workws CITYCompen- � POOL TOR y TEL. NO.
cation provisions of the Labd
rx Coe,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC
ed. WATER HEATER UCE tSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO.
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM WTLETS D
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, an5
d my license Is In full force and of- FINAL �//�JD TION
fact. HOSE BIB DATE O 'Ir y
License Number Lic. Class ACCT.T
FINAL
Contractor Date BY M,7 722•7 G¢7
I am exempt under Sec. 1 I TEM. V
B.BP.C. for this reason Plan check fee TOTAL 72-75 W
Data: PLUMBING PERMIT ISSUING FEE$ , CWX 1.751
Signature TOTAL FEE � ¢ •` I
SINGLE FAMILY
40AAE OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractors License Name — {
Low for the following reason (Section 7031.5, Businedr 4
ss and �] J1 `I1EI
Professions Coe): Address 5213 1 PM r'-6
El I, as owner of the property, will do the work and the city Tel. No.
structure Is not Intended or offered for sale(Section 7044,
Buslness pnd Professions Code). ,
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
(Sec. 3097, Civ. C.).
LerKiers Name
Lenders Address
I certify that I have read this appllcatlon and state that the ,
above Information Is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and heroby
authorize representatives of this County to enter upon the
abovo- endo operty for Inspection purposes.
a_q� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature ee —� Date