HomeMy Public PortalAbout9084 ACASO DR_Plumbing_1/6/1989_ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I Keieb+ affirm that I have a certificate.of consent to self in- 76A666 DPW 4/87
Y- 76A667A
sure, or a ceHificate of Workers'Compensation Insurance,or a CE.817(REV. 8/86)
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 }}��
Certified copy is filed with the county building inspection ADDRESS f/J GJ°�S O
department. NUMBER FIXTURE OR ITEM @ FEE // f
LOCALITY . Y11 L. C iJ
Date ' Applicant ' WATER CLOSET(TOILET) NEAREST
�
C
BATH TUB ROSS ST. �Q C /00 �. .
CERTIFICATE OF EXEMPTION FROM WORKERS'" /''
COMPENSATION-INSURANCE; SHOWER OWNER C L / J j.t4 r
(This section need not be completed if the work involved by MAIL /�
the permit is for one hundred dollars (;100) or less.) • LAVATORY _ ADDRESS. L 4 iu cl
I certify that in the performance of the work for which.this per- SINK ��"�
mit is issued, I shall not employ any person in any manner so CITY, TEL. NO.
as to become subject to the_/ •Worker; Compensation Laws. DISHWASHER '
l_�j/ & CONTRACTOR
DateApplican CLOTHES WASHER
NOTICE TO,APPLICANT: If, aADDRESSfier making this Certificate of Ex- "" SWIMMING POOL RECEPTOR
emption, you should become subject to the.Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
` ly with such provisions or this permit shall be deemed.revok- STATE LIC.
ed. WATER.HEATER /� LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION v DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER,SYSTEM FINAL VALIDATION
fect. DATE p
License Number Lic. Class U
fIN �
Contractor Date` B i O
El I am exempt under Sec. V
UJ
B.&P.C. for this reason
" Plan check fee ► �
Date: PLUMBING.PERMIT ISSUING FEE $
Signature TOTAL FEE `►`'
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plarn check applicant
I hereby affirm that i am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and
Professions Code): Address.':
I, as owner of the property, will do the work and the City Tel.'No. -
structure is not intended or offered for sale Section 7044, f" •a
Business and Professions Code). ( rl•"i °�
CONSTRUCTION LENDING AGENCY , 31017 16.50
I hereby affirm that there is a construction lending agency for E -
theerformance of the work for which this permit is issued
Sec. 3097,Civ. C.). p TOT4(.. 6
CNECK 16.50
Lender's Name
CHANGE .00
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 1/ t �JsG
3
ordinances and State laws regulating Plumbing, and hereby ;; �, siloc g
authorize representatives of this County to enter upon the
Db ve-mentioned propert for i spection urposes.
i/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee - Date