HomeMy Public PortalAbout9050 ACASO DR_Plumbing_2/20/1996WORKERS' CQMPENSATION DECLARATION
I hereby, aff`rm that I have a certificate of consent to self in-
sure, W. a certificate -of Workers' Compensation Insurance, or a
certified ccioy thereof (Sec. 3800, Lab. C.)
Policy Ncy a Company
Gartified copy is hereby furnished.
Certified copy is filed with the county building inspection
department.
Date D /
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so
as to become subject to the Workers' Compensation Laws.
Dat- Applicant
NOTICE TO APPLICANT: If, after making this Certificate of -Ex-
emption, you should become subject to the Workers' Compen-
sation provisions of the Labor Code, you must forthwith comp-
ly with such provisions or this permit shall be deemed revok-
ed.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and ef-
fect. ff
License Number�`�, b 0 5 [y Lic. ass
Contractor Date y r
am exempt under Sec. /
B.BP.C. for this reasonM.(i�_[/
Signature �d
SINGLE FAMILY
HO OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code):
1, 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 YAN ' " e D : 611oilo
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
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned,�ropert4-Fo inspection purposes.
Jntt�;."of Permittee Date
20-0026.DPW4,¢^!. 'APPLICATION FOR PLUMBING PERMIT
76A667A
COUNTY OF LOS ANGELES
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
NUMBER FIXTURE OR ITEM Q
WATER CLOSET (TOILET) �0
z BATH TUB
SHOWER
LAVATORY
SINK
DISHWASHER
CLOTHES WASHER
SWIMMING POOL RECEPTOR
LAWN SPRINKLER SYSTEMS
WATER HEATER
/ I GAS SYSTEM OUTLETS
OUTLETS OVER
5 PER SYSTEM
HOSE BIB
FEE
I�
Plan check fee
PLUMBING PERMIT ISSUING FEE $/ 7
TOTAL FEE
Plan check applicant
Name
Address
City Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
DEPT. OF PUBLIC WORKS
BUILDING
ADDRESS
I LOCALITY
NEAREST
CROSS ST.
i OWNERMAIL
ADDRESS
CIT�1.( TEL NO.
CONTRACTOR
ADDRESS
CITY
STATE
LICENSE NO.
DISTRICT NO. Y
��D
FINAL
DATE
FINAL
BY
TEL. NO.
LIC.
CLASS
PROCESSED BY
Q
)iIATION
156. 10
1 ITEMS
�
0
TOTAL -956- 10 =
CHECK
156.10
CHANGE
o00
0000-0001 21/20/96
4920 1 PM12a03