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Home My Public Portal About9082 ACASO DR_Plumbing_0 WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMB NG PERMIT I hereby, affirm that I have a certificate of consent to self in- 20 0026 DPW 4/90 sure,or a certificate of Workers'Compensation Insurance,or a 76A667A -awvwk e4411 certified copy thereof(Sec 3800, Lab C ) Policy No Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC 46RKS _ ❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING /?O D;f /� /J1aw ,� EiCertified copy is filed with the county building inspection ADDRESS �j GO► (/sem Gy64K� , department NUMBER FIXTURE OR ITEM @ FEE - LOCALITY � � WATER CLOSET(TOILET) ��i�K/mow Ddte Applicant NEAREST , CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work Involved by MAIL the permit is for one hundred dollars($100)or less) LAVATORY' ADDRESS I certify that in the performance of the work for which this per- SINK CITY TEL NO mit is issued, I shall not employ any person-in any manner so as to become subject to the Workers'Compensation Laws DISHWASHER '/ CONTRACTOR Date `1 Applicant CLOTHES WASHER ADDRESS ��a '� NOTICE TO APPLICANT If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- CITY TEL NO�y � sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok- STATE /y' LIC /�/�� 04 ed WATER HEATER — LICENSE NO ®OF1G7 CLASS (,� , LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS �0 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION fect � , HOSE BIB DATE License Number %9/O? Lic Class ,� FINAL O Contractor j6 ,&& GC- Date BY C _ O I am exempt under Sec � � t'g 4 0 B 8P C for this reason `8- �. �t � t, Plan check fee �_lt3 i°,,� Date PLUMBING PERMIT ISSUING FEE$ pool i r _ Z Signature TOTAL FEE SINGLE FAMILY / f �-L 4 HOME OWNER-BUILDER DECLARATION' Plan check applicant _ I hereby affirm that I am exempt from the Contractor's License Name , Law for the following reason (Section 7031 5, Business and Professions Code) Address 131,100-03011 E/ ,- I, as owner of the property, will do the work and the City Tel No "I-, , °-+ structure is not intended or offered for sale(Section 7044, - _ _ 64-- Business 4'Business and 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 ) Lender's Name r Lender's Address I certify that I have read this application and state that the f 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-me nti on'edRgperty for inspection purposes IK—A" X-49 IV SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date