HomeMy Public PortalAbout9084 ACASO DR_Plumbing_11/29/1995_ WORKER S COMPENSATION DECLARATION 20 0026 DPW9/89
76A667A APPLICATION FOR PLUMBING PERMIT -
76A867
I hereb�gffirr41 at I have a certificate of consent to self insure ,
or certificdte of Worker s Compensation Insurance or a certified , �'C�
copy thereof(Sec 3800 Lab C) ) - - /�c � �/-
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV
Policy No` Company
Certified copy is hereby furnished❑ BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy is filed with the county budding inspection
department -NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date Applicant PP i WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERSBATH TUB CROSS ST
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the
SHOWER 1 MAP BOOK PAGE / PARCELS
permit is for one hundred dollars($100)or less) LAVATORY OWNER
I certify that in the performance of the work for which this permit MAIL
is issued i shall not employ any person in any manner so as to/ SINK ` ADDRESS
become subject to the Workers Compensation Laws
/ DISWASHER CITY + TEL NO
Date eAe.1' Applicant CLOTHES WASHER
NOTICE TO APPLICANT If after aking this Certificate of CONTRACTOR �6 r
Exemption you should become subject to the Workers Compensation
pensation SWIMMING POOL RECEPTOR ADDRESS�9 jr/� ��
provisions of the Labor Code you must forthwith complywith such d
provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM -
LICENSED CONTRACTORS DECLARATION / CITY������� TEL NO 'Y� }
I hereby affirm that I am licensed under provisions of Chapter 9 TER HEATER A /01 iia d
(commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE Nq�O J�O� CLASSSTATE
Professions Code and my license is in full force and effect V
OUTLETS OVER DISTRICT NOPROCESSED BY
5 PER SYSTEM �O� O
License Number (� �/ Lic Class c F�
` �W j FINAL
DATE V;L4LIDATION W
Contractor4e Date n gT'i'EMt�� (F� ('t Z
FINAL r 8
I am exempt under Sec BY
B&P C for this reason _ CHECK 43.40
Date
I - Plan check fee `
.,
CHANGE .00
Signature PLUMBING PERMIT ISSUING FEE•$
❑ - TOTAL FEE
SINGLE FAMILY Plan check applicant , , 0000-0001 11/29/95
HOME OWNER BUILDER DECLARATION Name y '3493 1 PM'b■05
I hereby affirm that I am exempt from the Contractors License Law °
for the following reason (Section 7031 5 Business and Professions Address
Code)
❑ _ City Tel No - -
I 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 , 4
performance of the work for which this permit is issued(Sec 3097
Civ C)
Lender s Name i f
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 pop.
and State laws regulating Plumbing and hereby authorize
representatives of this County to enter upon the above mentioned '
property for inspection purposes -
���'�i�v��/ ' ` - SEE REVERSE FOR EXPLANATORY LANGUAGE -