HomeMy Public PortalAbout9189 JAYLEE DR_Plumbing_12/6/1993_sprinkler syst ION
DECLARATI
WORKER'S I have
a certificate
of consent to 20-0026 DOW
PW 9/89 AP"PUCAMN FOR PLUMMNIG FIERNT
I hereby affirm that I have a certificate of consent to self insure, `
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.t.)
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV..
Pok No. Company
❑ J ..
Certified copy is hereby furnished. BUILDING
❑ _. FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS Ta, e Z.�� ��
Certified copy is filed with the county building inspection
department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY
Date Applicant WATER CLOSET NEAREST
LQ Dom_
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.'
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the
SHOWER MAP BOOK PAGE 'PARCEL
permit is for one hundred dollars($100)or less.) LAVATORY OWNER U-)
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as toSINK MAIL
become subject to the Workers'Compensation Laws. I ADDRESS
DISWASHER CITY j( TEL.NO.
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption,you should become subject to the Workers' Compensation SWIMMING POOL.RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS
provisions or this permit shall be'deemed revoked. AWN SPRINKLER SYSTEM low' 0
LICENSED CONTRACTORS DECLARATION CITY �� TEL.NO. �-
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER A
STATE LIC.
(commencing with..Section 7000) of Division 3 of the Business and LICENSE NO. CLASS 0
Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS V
OUTLETS OVER DISTRICT NO.� PROCESSED BY
5 PER SYSTEM ,-• O
License Number Lic.Class
FINAL '"'.o V
DATE l`L_ 1rL VAh"ibA�ON r LLI
�
Contractor Date ( � ','E
j �v°='-Z
❑- ,I am exempt under Sea �Q
FINAL
!it
B.&P.C.for this reason -j
Date: Plan check fee ss
f CHECK
PLUMBING PERMIT ISSUING FEE$ !� -
Signature
TOTAL FEE (.•!iYfIs3�
Plan check applicant
SINGLE FAMILY ' 12 ./
HOME OWNER-BUILDER DECLARATION Name 00010-0100 _
I hereby affirm that I am exempt from the Contractor's License Law _
for the following reason (Section 7031.5, Business and Professions Address 1' __�: j i`°iC;
Code):
City Tel. No.
I, as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). N
CONSTRUCTION LENDING AGENCY
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 ordinances
and State laws regulatingPlumbin and hereby authorize
res
repfives of this o my ent on the above-mentioned
pro rt or inspectio pur ose 93 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date