HomeMy Public PortalAbout4935 ARDSLEY DR_Plumbing__ r ' `WORKERS'COMPENSATION DECLARATION APPUCAMN FOR PLUMENG NG PI5RI1@ OV
I hereby,affirm that I have'4a certificate of consent to self 76A667A
insure, ora certificate df Workers' Compensation Insurance, CE 817(REV. 8/86) II JI
or o'certified copy thereof (Sec. 3800, Lab..C.)
COUNTY OF LOSANGELES DEPT. OF, PUBLIC WORKSpolicy No. Company .
❑ Certified copy'is hereby furnished. BUILDINGD
v_
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS `�{"��✓/ tom/ '–r��
Certified copy is filed With the county building i6spec- n
tion department. NUMBER FIXTURE OR ITEM .@ FEE LOCALITY
Date Applicant WATER CLOSET NEAREST
CROSS SL il({J
�m A E/O i lti Z�
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 1CJ'1 !•� !(&
COMPENSATION INSURANCEg OWNERt
(This section need not be completed if the work Involved by o SHOWER
,the permit is for one hundred dollars ($100)•or less.) LAVATORY Cat%�� MAIL VE .
ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK/ CITY �Lg/'�n. TEL. NOV
' �►�
so as to become subject to the Workers'Compensation Laws. DISHWASHER l•
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you, should;,,become subject to the Workers' CITY TEL. NO.
Compensation provisians.of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions ,or. this permit'shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS v y}
(commencing with Section 7000) of Division 3 of.the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL ✓ VALIDATION) �
DATE
License Number Lic. Class cc
FI
Contractor Date /
❑ I am exempt under Sec. ®'
tl1
B.BP.C. for this reason - Plan checkfee
Date; PLUMBING PERMIT ISSUING FEE$ D
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY N&-u- t
HOME OWNER-BUILDER DECLARATION Name -�/ '
I hereby affirm that I am exempt from the Contractor's License Address
Low for.the following reason.(Section 7031.5, Business and
VJ94 VE
Professions Code): City Tel. No.
1, as owner of the property;:will do'the work and the
structure is not intended or.offered for sale (Section
7044, Business and Professions Code). ;97464A .D
CONSTRUCTION LENDING AGENCY t( o 0 o a 0.5
I hereby affirm that there is a construction lending agency for 4- 0 0 0 0 5
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.). 1 0 - 4.0..5.0
Lender's Name 0 0 0 4 0,5
nder'sAddress 0 71 4 8 7
certify thq01A hqNe read this application and state that the D
bove info m ti n is correct. I agree to comply with all County
dinance a d State lbws egulating Plumbing, and hereby
thoiffe a ntatives this antro enter upon the
a ove-me t' n proper r inspection purposes '
SEE REVERSE FOR EXPLANATORY LANGUAGE .
Signature of Permittee (� Date