HomeMy Public PortalAbout10714 ARROWOOD ST_Plumbing_6/9/1989_water fixtures (2) �.
WORKERS'COMPENSATION DECLARATION 6=,1C�"PUCA7PON, FOR PL�U�� MMIC, PERMT
4:1. r s-
1'hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure„or a certificate of Workers' Compensation Insurance, 76A667A
or a certif.iecicopy thereof,(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No.- Company
Certified copy is hereby furnished.,
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �/�
Certified copy is filed with the county building inspec- ADDRESS” O 7/4—,f-_ ►C CU ao
.tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY ^
ItWATER CLOSET �/� C 1
Date Applicant 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 ($100)or less.) G�. MAIL _ `1/
LAVATORY ��, ADDRESS 0//
I certify that in the performance of the work for which this
SINK CITY .— TEL.•NO
permit is issued, I shall not employ any person in any manner LG �(
so as to become subject to the r rs'Co sCONTRACTOR ati Laws. DISHWASHER
/V t
�I•
Date Applica ` S CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
SWIMMING POOL RECEPTOR.
Exemption,''you should become subject to the Workers' CITY TEL NO
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such, provisions or this permit shall be STATE L ,7 �/ c LIC.
deemed revoked. WATER HEATER LICENSE NO. ` CLASS
LICENSED CONTRACTORS DECLARATION _ DISTRICT NO. ` PROCESSED BY
I hereby affirmthot 1 am licensed under provisions of Chapter 9GAS SYSTEM OUTLETS (��/ �}
'(commencing with Section 7000).of Division 3 of the Business OUTLETS OVER C�
and Professions Code,and m license is in full force and effect. 5 PER SYSTEM
y b FINALDATE VALIDATION a
License Number � �� �"�Lir_- Class Jo �,
L—I ! FINAL
Contractor � _ate FY
O.,
❑'' i am exempt under Sec. LJ
B.&P.'C. for this reason
Plan check fee U)
Date:
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
i hereby affirm-that I am exempt from the Contractor's License Address ACCT°v
Law for the following reason (Section 7031.5, Business and 307 �qe��,
Professions Code): City -Tel. No: 34.5 r
E' I, as owner of the property, will do We work and the 1 ITE
structure is not intended of offered for'sole (Section _
7044, Business and Professions Code). TOTS 34 o 50
CONSTRUCTION LENDING AGENCY MICK 34°''t
C0
I hereby affirm that there is a construction lending agency for
the performance of the work for ;CWHE
this permit is issued , �p�,�HE
(Sec. 3097, Civ. C.).
Lender's Name
QOD-0w1 b/ 9/U9
Lender's Address 3864 1 AN 9 Oo
I certify that I have read this application'and state that the P1 7
above information is correct. 1 agree to comply with all County
ordinances and State lawsre ulating Plumbing, and hereby
u r' representatives of is County to enter upon the
er�ioned rap rty fo nspection purpo s.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee ate