HomeMy Public PortalAbout10037 BOGUE ST_Plumbing_5/22/1987 \ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
gffirm that I have o certificate of consent to self 76A667A
i " re, or a ccrt-ficate of Workers' Compensation Insurance, CE 817(REV 10/81)
or a certified copy thereof (Sec. 3800, Lab C.) COUNTY F LOS AN ELES BUILDING AND SAFETY'
Policy No Campa
Certified copy is reby f fished. s' Y
�' FOR AP CAN O FILL IN( INT OR TYPE) BUILDING
ADDRESS Lj r
Certified copy is i d it e county building inspec-
tion department NUMBER FIXTURE OR ITEM @ FEE LOCALITY o ✓JL
Date ,I A c nt WATER CLOSET
NEAREST
CERTIFICAT F EM TION FROM WORKERS' BATH TUB CROSS ST
COMPENSATION INSURANCE OWNER
SHOWER-
(This section need not be completed if the work Involved by MAIL
the permit is for one hundred dollars ($100).or less.) LAVATORY ADDRESS
_ I certify that in the performance of the work for which this
permit is issued, I shall not employ,any person in any manner SINK CITY TEL Nq4(�1,:1jgj
so as to become sublect to the Work 'C tion Laws. DISHWASHER I
CONTRACTOR )t-9.1
- .1 v .
Date Applicant - ' CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS
Exemption, you should become SWIMMING POOL RECEPTOR subject to the Workers' CITY j� TEL
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM (! ( r
with-comply with such provisions or this permit shall be STATE LIC.
deemed revoked WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTR T NO PROCESSED BY
I hereby affirm"that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER a
and Professions Code, and my license is in full force
�and effect 5 PER SYSTEM FINALV
VALIDATION
License Number Lic. Classes Z2721/'
0
FIN O
09
Contractor ate B U
❑ V
LU
I am exempt under Sec CL
' til
B 8P C. for this reason
- . . Plan check fee '
PLUMBING PERMIT ISSUING FEE$
tgnature ], (Y' AM
TOTAL FEE
Z r Plan check applicant ,
'' r.• SINGLE FAMILY '
HOME OWNER-BUILDER DECLARATION Name
I herebyaffirm thahf a L exempt-from the Contractor's License
,
Law for the following. ea
_rson (Section 7031 5, Business and Address,' ,
Professions Code) City Tel. No
I, as owner of the prope >J;swill do the work and the 2 4 7 6 5� A
structure is not intended oP,yAbred for sale (Section ,
7044, Business and Professionsde),y,m # o o o X0',0 5
CONSTRUCTION LENDING ALAN-,"Ya"l, (•• s� 650
I hereby affirm that there is a construction leni*jggragen cy for °'°
the performance of the work for which this periniti'rs:issued _
(Sec. 3097, Civ. C ) Q� ti ° •'O J� O c�
Lenderos Name 0 603=86-
Lender's
03=86-_Lender's Address
Icertify 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
abo7,njtied pro rty for inspection purposes SEE REVERSE FOR'EXPLANATORY LANGUAGE
Si _ature of Permittee Date
1