HomeMy Public PortalAbout9027 ACASO DR_Plumbing_9/17/1986_water closet, shower, lavatory KERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
rm thdt`'I have a certificate of consent to self 76A667A
certificate of W�rkrs"Cffimpensatio: Insura'ric�e, CE 817(REV. 10/81)
d copy thereof-(Sete 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑ Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ^^►►4
Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant WATER CLOSET NEAREST G �✓
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST.
COMPENSATION INSURANCE �' SHOWER r OWNERAon C /e
(This section need not be completed if the work involved by MAIL op
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS c! V
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO.Ll� ,�J
so as to become subject to the Workers Compensation Laws. DISHWASHER
CONTRACTOR
Date G Applicant a-4 12 ;�: CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate o
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 0,?
CAL
r
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER p
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
DATE '
License Number Lic. Class C)
FINAL U,
Contractor Date BY W
❑ 1 am exempt under Sec.
U
B.&P.C. for this reason 6td
Plan check fee
Date: N
PLUMBING PERMIT ISSUING FEE$ /(J Z
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY J
HOME OWNER-BUILDER DECLARATION Name t
I hereby affirm that I am exempt from the Contractor's License Address Z 7
Law for the following reason (Section 7031.5, Business and
ProWfessions Code): City �r le- Tel. No. Z
X1, as owner of the property, will do the work and the
, structure is not intended or offered for sale (SectionOpp, 5 4 5, 1 A
7044, Business and Professions Code).
# o o' o 0 0 5
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for I o o 2 8.5.0
the performance of the work for which this permit is issued o J
(Sec. 3097, civ. C.). o o 2 8.5 0 1—
Lender's Name
0 9. 1 7=86
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 lows regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned grope y for inspection purp ses.
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SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o ermi tee D to