HomeMy Public PortalAbout10684 ARROWOOD ST_Plumbing_7/9/1991_water fixtures, gas system -WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �7
wh-,,t;*y.affirm that I have a certificate of consent to self 20-0026 DPW 6/87 [, I
insure, or,a certificate of Workers' Compensation Insurance, 76A667A lug
or certified copy thereof'(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Poliry No. Company
D'. i ertified copy is hereby furnished.
DFOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDINGell ��p
Certified copy is filed with the county building inspec- ADDRESS rigr 0 a4
tion department. NUMBER FIXTURE OR ITEM Q FEE_ LOCALITY le,
CLOSET NEARESTrfiv
Date Appligant CROSS ST. GC I
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB
COMPENSATION INSURANCE SHOWER D OWNERf<e
(This section need not be completed if the work Involved by MAIL
11
the permit is for one hundred dollars($100)or less.) LAVATORY �Q ADDRESS S G[ �-
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
Q' CONTRACTOR 0
Date Applicant I 'CLOTHES WASHER ADDRESS �"
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �r?�
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
DATE ` ®.
License Number Lic. Class i 0
FINAL / � /�
Contractor Date BY 0�/ /
DI am exempt under Sec. W
B.&P.C. for this reason
Plan check fee ® Z
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE LI
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I herebyaffirm that I am exempt from the Contractor's License
P
Law for the following reason (Section 7031.5, Business and Address _
Professions Code): City Tel. No. =')=� (=°Ji=
l�J «'
I, as owner of the property, will do the work and the ;, p !•(_�`i_
structure is not intended or offered for sale (Section c K .
7044, Business and Professions Code). , r I.1{r1L_ Baa a 50
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 'ifii 1 {a
(Sec. 3097, Civ. C.).
Lender's Name - -.
Lender's Address -;�. t ,t ,yu
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
,T 9 ' ri/6rd ��
Signature of Permittee Date