HomeMy Public PortalAbout10031 BOGUE ST_Plumbing_10/16/1980_1729-44 WORKERS'COMPENSATION DECLARATION 78A687A - APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I .have a certificate of consent to self CE: 817 (2-80)/
insure, or a certificate of Workers'Compensation Insurance,or
ac�rti�i�d cry thereof(Sec. 3800, ab.C,,.)� //'
;• ;,,, J'�"�C. COUNTY OF LOS ANGELES � - BUILDING AND SAFETY >
Policy No. Company
�� r S o�;.� A,y c
Certified copy he y rnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
� ADDRESS /6 0
U Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE
LOCALITY �• �r
,1 artm pt. L�}�� WATER CLOSET
Date —7[. Applicant Llf 7`� NEAREST
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved LAVATORY MAI LADDRESS 4—
by the permit is for one hundred dollars ($100) or less.) SINKa
CITY TEL.NO. O
I certify that in the performance of the work for which this DISHWASHERU
permit is issued, I shall not employ any person in any manner CONTRACTOR ' f /G��-
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER ADDRESS, �3 jn/L� 0
Date Applicant SWIMMING POOL RECEPTOR 'J
NOTICE TO APPLICANT: If, after making this Certificate of CITY �Z'7e= TEL. NO.YY�Z d
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE �y cj LIC.
Compensation provisions of the Labor Code, you must forth- LICENSE NO. �7 / CLASS ��� Z
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. P OCESSED BY
LICENSED CONTRACTORS DECLARATION - OUTLETS OVER J j L
I hereby affirmthat I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL///•�� VALIDATION
ness and Professions Code, and my license is in full force and DATE / t/ "�
effect.
FINAL
License Number ZY9H 3114V Lic.Class C�G BY �^�•'� t
Contractor Rf'15 )7 Date /4) –/CV O nnv,�
I am'exempt from the licensing requirements as I am a Plan check fee A, W�-
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
{
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE
Lic.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name '2 6 k 1 A
I hereby affirm that I,am exempt from the Contractor's Address
License Law for the followingreason Section 7031.5, Busi- # o-0 0 0 0
( City Tel.No.
ness and Professions Code): 2'- 01 0. 0 0
I, as owner of the property,'am exclusively contracting
with licensed contractors to construct the project o 0 0 1 d.0 01F
(Section 7044, Business and Professions-Code).
10,:16-80
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plu mg, and hereby
authorize representatives of this -ounty enter upon the
above-mentio a ro y for' pectin rposes.
Wre o Per ee Date