HomeMy Public PortalAbout4857 ARDEN DR_Plumbing__ WORKER'-Cpg,W'' ATfON DECLARATION . APPLICATION FOR PLUMBING PERMIT
I hereby;affirm thot IA a cectif!cate of consent to self 76A667A
insure, or-a certificate of Workers'Compensation Insurance, CE 817(REV. 8/86)
or a cehe of tifie c t3800, La C.
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Policy �e COUNTY OF LOS ANGELES DEPT. OF'PUBLIC WORKS
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❑ C rtified copy is hereby furnished:
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING .,
Certified copy is filed with the t bui g inspef. ADDRESS
V
de rt e. NUMBER FIXTURE OR ITEM p FEE
' LOCALITY
Date r - Appli4arit WATER CLOSET NEAREST
CERTIFICATE OF EXEMP I FROM WORKERS' BATH TUB CROSS 57. U
COMPENSATI INSURANCE SHOWER OWNER
(This section need not be completed if the work tnvolved by MAIL
-the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this y
permit is issued, I shall not employ any person in any manner r SINK CITY TEL. NO.
so as to become subject to the Workers'Compensation.Laws. DISHWASHER
• CONTRACTOR f s •
Date Applicant CLOTHES WASHER ADDRESS 7 �-
t NOTICE TO APPLICANT: 'If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor'Code, you must forth- LAWN SPRINKLER SYSTEM CITY is �") EL. NO
with comply with such provisions or this permit shall be STATE / c� LIC. /t
' deemed revoked. WATER HEATER /)71 LICENSE N.6X &X CLASS, �r
LICENSED CONTRACTORS DECLARATION (�(1 DISTR9CL1,40. P CESSED BY
GAS SYSTEM OUTLETS G
I hereby affirm that I am licensed under provisions of Chapter 9 r
(commencing with-Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect 5 PER SYSTEM FINAL O
DATE C/
License u Lic. lass cc
^ FINAL
Co BY
L!J
I am exempt er Sec.
B.&P.C. for this reason
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE S .;p 7 6 211 A
Plan check applicant
SINGLE FAMILY # ° ° ° ° ° 5
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address .1 ° - 34,50
Low for the following reason (Section 7031.5, Business and 3 11,5 0
Professions Code): City Tel. No. o,o 0
❑ I, as owner of the property,.will do the work and the 0 a 0 7 a 8 7
structure is not intended or offered for sale (Section
7044, Business and Professions Code). PIP
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 Nome
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 and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
,, aib -men' ed property for inspection purposes.eSEE REVERSE FOR EXPLANATORY LANGUAGE
Sgnature of Permittee ,, Q� ;;;Rote