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HomeMy Public PortalAbout10835 ARROWOOD ST_Plumbing__ WORKERS'COMPENSATION DECLARATION A'Pn �C A Uj �OH FOR PLUMBING L ��p�BI G PERWT I hereby, affirm that I have a certificate of consent to self in- 20-0�A FW 490 Lf- surf,,or a certificate of Workers'Compensation Insurance,ora certified'copy thereof (Sec. 3800, Lab. C.) Policy No./ 7/?9 Company_-S%ATt �r' VZ COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS ❑ Certified copy is hereby furnished: BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ( C ��/�,(, Certified copy is filed with the county buil g inspection . . ADDRESS /O S/ J department. NUMBER FIXTURE OR ITEM Ca ' FEE LOCALITY Date S /1 I/ WATER CLOSET(TOILET) NEAREST 3 Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. 0 C, J COMPENSATION INSURANCE SHOWER OWNER Y, (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) VATORY ADDRESS I certify that in the performance of the work for which this per- SINK mit is issued, I shall not employ any person in any manner so CITY. 27Z TEL. N as to become subject to the Workers Compensation Lows: DISHWASHER' t 7 T CONTRACTOR Date. Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this-Certificate of Ex- ADDRESS `L^ 4V—,<'J k emption,you should become subject to The Workers'Compen- SWIMMING POOL RECEPTOR CIT / TEL. NO. cation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS C' ly with such provisions or this permit shall be deemed revok- STATE )) / c, LIC. ed. WATER HEATER LICENSE NO. L {0 7 CLASS LICENSED CONTRACTORS DECLARATION. DISTRICT NO. PROCESSED BY I hereby affirm that I'am licensed under provisions of Chapter GAS SYSTEM OUTLETSO� Y 9(commencing with Section 7000)of Division 3 of the Business OUTLETS.OVER eSr e_ and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL 2 t ' I ATION fect. HOSE.BIB DATE' �/� � License Number 4> /� Lic. Class ., TT r �+ FINAL ,9303 43.40 V Contractor l f;q_.l idtiEl zl- 3 Sate BY 1 ITEMSI am exempt under Sec. O TOTAL �`e� © 4••0 B.BP.C. for this reason "' t LU Plan check fee NECK 43°40 y Date:' PLUMBING PERMIT ISSUING FEE$ CHANGE v00 Signature SINGLE LY TOTAL FEE HOME OWNER-BUILDER(DECLARATIONPlan check applicant a 000001 3/18/96 I hereby affirm that I am exempt from the Contractor's License Name, 5351. 1 AM 10=07 Law for the following reason' (Section 7031.5, Business and Professions Code):'. Address as owner of the property, will do the work and the City Tel. No. structure is not intended or offered for sale(Section 7044; Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm.thot 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 oinfor h e read this application and state that the ion s corre t. I agree to comply with all County d ate law regulating Plumbing, and hereby r entatives of this myto enter upon the ned pr ert for i s e tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE gnature of Permittee Date