HomeMy Public PortalAbout10545 DANBURY ST_Plumbing_5/17/1982_dishwasher WORKERS'COMPENSATION DECLARATION 76A667A
I hereby affirm that I have a certificate of consent to self cc en Ia-eol APPLICATION FOR PLUMBING PERMIT
insure, or a certificate of Workers'Com ensath n Insurance,or ,
a certified copy thereof(Sec.3800, La C
- COUNTY OF LOS ANGE L IN N SAFE
Policy No. Company - ` f
n Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS
Certified copy is filed with the county build r inspection NUMBER FIXTURE OR ITEM ® FEE
art en LOCALITY
WATER CLOSET
Datepplicant / NEAREST
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORK'
COMPENSATION INSURANCE SHOWER OWNER
MAIL
(This section need not be completed if the work involved
LAVATORY ADDRESS d
by the permit is for one hundred dollars ($100) or less.) SINK
CITY TEL.N0.VV
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I certify that in the performance of the work for which this DISHWASHER - cc
permit is issued, I shall not employ any person in any manner CONTRACTOR O
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHERU
ADDRESS
Date ApplicantIle W
SWIMMING POOL RECEPTOR } d
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.N �xj,�j W
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. )/ Z
Compensation provisions of the Labor Code, you must forth-
withHEATER LICENSE NO. ��� CL V y�
with comply with such provisions or this permit shall be
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NNO.fJ` R CESS By
LICENSED CONTRACTORS DECLARATION OUTLETSOVER
1 hereby affirm that 1 am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL ,r y VALIDA N
ness and Professions Code, and my license is in full force and DATE ��ri -�lh.
effect. ry / '( L
License Nu}m��b�fJb 6?/l�`1e Lie. Class C � -By
AL
Contractor(( /�t� ate ��d ��
I am exempt from the licensing requirements as I am a Plan Check fee ��(�V
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE
Lie.or Reg.No. Date LAdd,e�.
check applicant
HOME OWNER-BUILDER DECLARATION e
24029A.
I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason Section.7031.5, Busi- Jr( Tel. No.
ness and Professions Code):
Ell, as owner of the property, am exclusively contracting 2 0 01250
with licensed contractors to construct the project 'o ego2 Jr 0 v
(Section 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 7.—8 2
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the .
above-mentioned prop ty for inspection purposes.
41!�&2 44 f (-; a
Signpure of Permittee Date