HomeMy Public PortalAbout9073 ACASO DR_Electrical_6/21/1982_fixtures WORKERS'COMPENSATION DECLARATION CE 81 APPLICATION, FOR-PLUMBING
A , + PERMIT
I hereby affirm that I have a certificate of consent to self ce s�7 Iz-eo) '�
insure, ossa certifiGate of Workers'Compensation Insurance,or "
wlcv sed cop thg c 380 , a � ,� C; COUNTY OF LOS ANGELES BUILDING AND SAFETYNo Compa , -
Certified copy is hereby furnished`/ � FOR APPLICANT TO FILL IN (PRINT OR TYPE)- BUILDING
s
It- ADDRESS ® !?
❑ Certified copy is filed with the county buildspection NUMBER FIXTURE OR ITEM • FEE
department WATER CLOSET LOCALITY M _
Date Applicant _ NEAREST
BATHTUB ' CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER G'v1
(This section need not be completed'if`the work involved LAVATORY ADDRESS
by the permit is for one hundred dollars ($100) or less) SINK - Y �m CL
,�' CITY TEL NO�� 0
I certify that in the performance of the work'for which this DISHWASHER, U
permit is issued, I shall not employ any,person in any manner CONTRACTOR/7
so as to become subject to the Workers' Compensation Laws CLOTHES WASHER ��� 0
ADDRESS
Date Applicant a+' SWIMMING POOL RECEPTOR W
NOTICE TO APPLICANT If, after making this Certificate of CITY TEL! TEL NODI a
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM , to
Compensation provisions of the Labor Code, you must forth- ^ STATE pl 4�-Z CLASS LIC z
-with comply with such provisions or this permit shall be WATER HEATER LICENSE N J
deemed revoked !� DISTRICT NO 4R ESSED BY-
GAS SYSTEM ! OUTLETS �
LICENSED CONTRACTORS DECLARATION, , OUTLETS OVER i O O
1 hereby'affirm that I am licensed under'provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL /
ness and Professions Code, and my license is in full force and, DATE VALIDATION
Z(
effect s ,
FINAL
' License Number Lic Class BY
Contractor Date S -
�' I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer p/ ,+
PLUMBING PERMIT ISSUING FEE$
acting'in my professional capacity (Section 7051, Bus- U
iness and Professions Code) TOTAL FEE �p t
Lic or Reg No Date Plan check applicant
' r .
HOME OWNER-BUILDER DECLARATION Name
Address
I hereby affirm that I am exempt from the Contractor's ';125661 A
License Law for the following reason (Section 7031 5, Busi- City Tel No
ness and Professions Code) # • • • • •,5
' I, as owner of the property, am exclusively contracting 1 5
• i
with licensed contractors to construct the project .. _ ,
(Section 7044,Business and Professions Code) r • e'• 11&5.0 C5
CONSTRUCTION LENDING AGENCY O 7-82 ,
I hereby affirm that there is a construction lending agency i `
.for the performance of the work for which this permit is
issued(Sec 3097,Civ C)
Lender's Name '
Lender's Address ^ r
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
ab o a-me ion awroperty inspectionpur oses
ZZZZSignature of Permittee Date