HomeMy Public PortalAbout9030 ACASO DR_Plumbing_4/18/1985_solar A."
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
1 her,;by,r41rr0hot I have a certificate of consent to self 76A667A ,
insure, or a certificate of Workers'Compensation Insurance, CE 817(REV 10/81)
or a certified copy thereof (Sec 3800, Lab C )
Policy N -1� Company r COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certif d copy is hereby furni hed
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS
tion department NUMBER FIXTURE OR ITEM FEE LOCALITY
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Date Applicant �- WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars($100)or less) LAVATORY MAIL t
I certify that m ADDRESS 14 Casio
The performance of the work for which this ..
permit is issued, I shall not employ any person in any manner 'SINK CITY TEL N07
so as to become subject to the rs'Com sa n Laws DISHWASHER w L
/1� - CONTRACTOR
Date 4— -?�Applican s/ -1 CLOTHES WASHER ADDRESS, c
1 NOTICE TO APPLICANT If, afte making this ertificate of S�
Exemption, you should become subject to,the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL NO
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM
STATE LIC
deemed revoked WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROC SED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS it(jI'
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER , V
and Professions Code,and my license is in full force and effect 5 PER YSTEM
/ FINAL VALIDA ONf DATEV 0
_7 License Lic Class-
ME
lass
nscAo-0�! Q5(I' VO
Date
❑ I am exempt under Sec - Wd
B&P C for this reason Plan check fee ;1 1 S G 9 A Z
Date
Signature # • • e o • 5, , �� ►
- PLUMBING PERMIT ISSUING FEE$ -
TOTAL FEE St✓ • • 3 Q'5 0
SINGLE FAMILY
Plan check applicant to • • 3(15,0
' `
HOME OWNER-BUILDER DECLARATION Name eW 04, 18-85
I hereby affirm that I am exempt from the Contractor's License Addres 4
-Low for the following reason (Section 7031 5,.Business and 7
Professions Code) City Tel No
❑ 1, as owner of the property, will do the work and-the °
L t 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 +
r
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 oll'County
ordinances and State laws regulating Plumbing, and hereby
authorize repre ntatives of this County to enter-upon the -
above-ment a ;p?rler for inspection purposes
.r _ SEE REVERSE FOR EXPLANATORY,LANGUAGE
''� 5740
2 ,
f7g-naturp,bf,Permitted Date