HomeMy Public PortalAbout10648 ARROWOOD ST_Plumbing_5/28/1985_solar water heater • L
WORKERS'COMPENSATION DECLARATION A ppUCAp MN FOR PO Lv u�1 utlu�u M fl MIG (u�ERWT
I hereby affirm that I have a,certificate of consent to self 76A667A
in,ure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
��oyyr��acertified copy thereo(ff((Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND.SAFETY
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7ic�y PRS`/ 1 Company
❑ Certified copy is hereby furnished. _
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS
do depart ent.• _ NUMBER FIXTURE OR ITEM' @ FEE LOCALITY—Ge C—Av.
WATER CLOSET
Date 1 Applicant NEAREST
CERTIFI ATE OF EXEMPTION FROM" RKERS' BATHTUB. CROSS ST.,.
COMPENSATION INSURANCE SHOWER OWNER ei (W(This section need not be completed if the work involved by
the permit is for one hundred dollars($100)or less.) MAIL
LAVATORY ADDRESS
I certify that in.the performance of the work for which this 1
permit is issued, I shall not employ any person in any manner SINK CITY �i^� TEL. NO, �
so as to become subject to the Workers'Compensation Laws. f ,Ole DISHWASHER 111
+ CONTRACTOR (
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS L �^
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY CA TEL. NAIa .
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE �j�i LIC.
deemed revoked. WATER HEATER LICENSE NO. F�C CLASS C"
LICENSED CONTRACTORS DECLARATION DISTRICT O. P OC SED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS /) (o/ I{�(j�!
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER r (�
and Professions Code,and m license is in full force and effect. 5 PER SYSTEM _
y FINAL J VALIDA O�
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Lavaucnie DATE (� 0
License Numberilq ft;1 Lic. Class--l—A0
$e�C°W�rr�ttt .56 1ckk FIN
Contract Date '' BY
❑ 2 2.1 1,4 A I am exempt under Sec.
#.O
B.&P.C. for this reason 0 0 0 0 5 �
Plan check fee I o 0 395,0
Date:
- PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE '0 0 0 3 0,5 0
Plan check applicant
SINGLE FAMILY O 5 2$=$5
HOME OWNER-BUILDER DECLARATION - Name
I hereby affirm that I am exempt from the Contractor's License Address,
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
❑ 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).
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 hove 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
ve-m�mspectfonfurpos7.t ( _ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Dclte