HomeMy Public PortalAbout9058 ACASO DR_Plumbing_4/21/1992 WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
'insure, or a certificate of Woikers' Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
❑ ,
Certified copy is hereby furnished.
� FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
17 Certified copy is filed with the county building inspec- ADDRESS �C
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Appligant WATER CLOSET d NEAREST y-
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNERN e ��
(This section need not be completed if the work Involved by
the permit is for one hundred dollars $100 or less. MAIL
P ( ) ) LAVATORY lJ ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY 1 4s TEL. NO
so as to become subject to the Workers Compensation Laws. DISHWASHER c'•2
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL. NO.
P P Y LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER O
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL
Q
VALIDATION
DATE
License Number Lic. Class ..�—
C�.
FINAL •
Contractor Date BY ''
El am exempt under Sec. IF
'CIF
`"
B.BP.C. for this reason Q�
Plan,check fee
Date:
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL'FEE /
"H .
Plan check applicant Cr_ - ___ ..__
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Namef''"
I hereby affirm that I am exempt from the Contractor's License Address
L vv for the following reason (Section 7031.5, Business and
ofessions Code): __ '.'• ' t.'. F. i.
City Tel, No.
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). Pr
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 poll
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
abov -menticned'property f inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ala '
Signature of ermittee �T—D—Ate