HomeMy Public PortalAbout4947 ARDSLEY DR_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
insure or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
�r a certified copy thereof (Sec. 3800, Lab. C.)
,. -s/ COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company 4!
❑ Certified copy is hereby fu fished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
�'i �' WATER CLOSET
Date Applicani/.�-SS�r%�.� NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by
the permit is for one hundred dollars (5100)or less.) LAVATORY MAIL
ADDRESS Al ec3 G G �O
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 TEL. NO.
so as to become subject to the Workers Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of --f,
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY LAWN SPRINKLER SYSTEM TEL. NO_-5-: -,7
.
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Compensation provisions of the Labor Code, you must forth- 'y .+ , "" j�7Jd
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO.ma ADO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER y
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL �. _ VALIDATION
c� DATE �'"
License NumberPLic. Class A0 U
FINAL t9
Contractorto BY G.-
I am exempt under Sec.
EIiD
B.&P.C. for this reason
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address a c n c c
Law for the following reason (Section 7031.5, Business and `
Professions Code): City Tel. No. e9 a L F C
❑ I, 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). ' J
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
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
above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Permittee D to