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WORKERS'COI)Ive a c T4ON.DECLARATION I APPLICATION FOR PLUMBING PERMIT
I h`b?eb a#trm that I have a certificate of consent to self in- 20-0026 DPW q/87 f�
Y• `,ILJIj
:sure,or a certificate of Workers'Ciimpensafibn Insurance, 76A667A;or CE 817(REV.8/86) 1
certified copy.thereof(Sec. 3800, Lab. C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby furnished. i
Certified copy Is filed with the count building p I FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRBUILDESS
3 � Xv
department. Y gins inspection NUMBER FIXTURE OR ITEM @ FEE ADDRESS 'L �i(
7
• Date Applicant I WATER CLOSET(TOILET) ! �U LOCALITY i 172
�i [.P&�5 C/
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'. BATH TUB j 0 CROSS ST.• Q/V6b0A)�/
COMPENSATION INSURANCESHOWER O OWNER ����, /�
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY L 2. (�Q ADDRESS 1 5 Q0 G0A4,6 Jai/
I certify that in the performance of the work f r which this per- SINK
mit is issued, I shall not employ any perso y ma ner so I pO CITY �M�j TEL. NO.
as to become subject to the Workers'Co f'e s I n rs. i DISHWASHER CONTRACTOR r W TJ
Date . — Applicant ' I CLOTHES WASHER I b�
NOTICE TO APPLICANT: If, after ma Ing this Certificate of Ex-
emption,you should become subject to the Workers'Compen- I SWIMMING POOL RECEPTOR
CITY TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
•ly with such provisions or this permit shall be deemed revok- STATE LIC.
.ed. WATER HEATER �j LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION ppp111SSSTTTRICT NO PROC�EOD aYY�
I hereby affirm that I am licensed under provisions of Chapter ; GAS SYSTEM OUTLETS 6�
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER V
and Professions Code, and my license is in full force and ef- 1 5 PER SYSTEM FINAL VALIDATION }
fect. DATE )i a
License Number Lic. Class i U
FINAL
Contractor Date BY O
U
I am exempt under Sec. W
B.&P.C. for this reason •�" � ti
Plan check fee '- rn
�*y -•, .-, �-� tl l
Date: PLUMBING PERMIT ISSUING FEE$ :::] SV -•--• •' -
Signature
i TOTAL FEE �•+ _• =I wl I'�
SINGLE FAMILY �J U a
HOME OWNER-BUILDER DECLARATION Plan check applicant _50
I hereby affirm that I am exempt from the Contractor's License Name 1 f•i�giv
Low for the following reason (Section 7031.5, Business and !'l.
Professions Code): Address
❑ 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, „�• a -.fC.,
Business and Professions Code). ® •_ —•
i, a--
CONSTRUCTION LENDING AGENCYJ.
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.).
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
ordinances a d §tate laws regulating Plumbing, and hereby
authorizer ntafiv s of this County to enter upon the
above-m o o for inspection purposes.
s cE.�' SEE REVERSE FOR EXPLANATORY LANGUAGE
Signat o e rnittee Date