HomeMy Public PortalAbout10656 ARROWOOD ST_Plumbing_4/26/1985_gas system •yo WORKERS' COMPENSATION DECLARATION A f7 P C/�1 5���N FOR oP fl fl/l�l•[��f G j�a 2 f�11/1�t,
w try if if LL fi�1 ll ll V FOR u L�lJ U V Il v G�l u LS EI [Il°Itl hl
t• I herd by affirm that I have a certificate of consent to self 76A667A 10
insure, or a certificate of Workers' Compensation Insurance, CE 81.7.(REV. 10/81)
or a certified copy-thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.5ATZ37 Company
Certified copy is hereby furnished'.
^ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ./A
yt�a/] Certified copy is filed with the county building inspec-. ADDRESS lu
tion department. NUMBER FIXTURE'ORITEM- @ FEE LOCALITY G. 1
Date v Applicant 6�1 _ WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER S ��
(This section need not be completed if the work involved by MAIL -
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS !j 6 r ka wo
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY PC TEL. NO. !
l Eft
so as to become subject to,the Workers Compensation Laws. DISHWASHER
CONTRACT C E
Date Applicant CLOTHES WASHER ADDRESS
C I
NOTICE-TO APPLICANT: If, after making this Certificate of - , lL
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you-must forth- CIT. VVII to
TEL NO:
with,comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATE r I f LIC.
deemed revoked. WATER HEATER LICENSE NO. 411ee CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO_�/ PR ESSED BY
I hereby offirrrh&t I am licehsed under provisions of Chapter 9 GAS SYSTEM OUTLETS �{T
(commencing with`Section 7000) of Division 3 of the BusinessOUTLETS OVER
and Professions Code,and.my license is in full force and effect. 5.PER SYSTEM
QQ /l DATVALID*ION
License Number 9 L 1 v v 0 Lic. Classy^� Ef ' U
, / ,.`.
FINAL f�G
Contractor G tF T `'Y-�`t-�S BY / y
❑ I am exempt under Sec. Lu
B.BP.C. for this.reason
Plan check.fee z 1 9 3'1 'A,
Date:
-PLUMBING PERMIT ISSUING FEE$
Signature
�`i. # o,o o:-o o 5
-� ,
TOTAL FEE ( o -.1650
Plan'check applicant
SINGLE FAMILY
0 0
.HOME OWNER-BUILDER DECLARATION Name -•''YT1 �- 'G a- •, 0 1 6, 50 C-)2
I hereby affirm that I am exempt from the Contractor's License Address v
Law for the following reason (Section.7031.5, Business and S ® K 0 4,26
Professions Code): Ci 1 42 L- 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)'.
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 regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date