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WORKER'S COMPENSATION DECLARATION 20-0026 DPW 9/89 p�������1®i►1 �®1"9 I�I����IIY� ����I�
76Ae57A APPLICATION I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.C.)
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
Policy No. Company
❑ Certified copy is hereby furnished. ADDRESS
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE)
Certified copy is filed with the county building Inspection
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. �d �tzeq COMPENSATION INSURANCE ASSESSOR
(This section need not be completed If the work Involved by the SHOWER MAP BOOK PAGE PARCEL
permit Is for one hundred dollars($100)or less.) LAVATORY OWNER
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as toSINK ADDRESS gy $,���,,,� Qd�
AIL
become subject to the Workers'Compensation Laws.
DISWASHER CITY e0&k 4PC-41 TEL.N0.297 3v'7V
Date Applicant CLOTHES WASHER CONTRACTOR �
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code,you must forthwith comply with such ADDRESS
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO.
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER a
(commencing with Section 7000)of Division 3 of the Business and LICENSE NO. CLASS O
Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS QE7 (�
OUTLETS OVER DISTRICT NO. PR S O
5 PER SYSTEM U
License Number Lic.Class V
FINAL _
DATE VALIDATION W
11
Contractor Date U)
❑ FINAL i Z
I am exempt under Sec. BY I
BAP.C.for this reason 5
Date:
Plan check fee -!® a
; :s To a
PLUMBING PERMIT ISSUING FEE$ vUs
Signature `� j�;il{ ;tu -i
TOTAL FEE
❑ `� 1 ITEM.
EM
SINGLE FAMILY Plan check applicant TOTAL 40 .65
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law CHECK
for the following reason (Section 7031.5, Business and Professions Address
Code): CHANGE .00
I,as owner of the property,will do the work and the structure City Tel.No.
is not intended or offered for sale(Section 7044, Business
and Professions Code). 131313113-001001 5' 1'/9
•.1 i
CONSTRUCTION LENDING AGENCY 9542 f Ali &:Cls:
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
1 certify that I have read this application and state that the 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 above-mentioned
grope for' spection ur o, s. SEE REVERSE FOR EXPLANATORY LANGUAGE
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Ilqinature of Permittee Date