HomeMy Public PortalAbout9018 RANCHO REAL RD_Plumbing_6/23/1986_bathroom fixtures • ► WORKERS'COMASATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
in'9ure, or a-certificate of Workers'Compensation Insurance,, CE 817(REV. 10/81)
or a r':ertified copy thereof(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
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
tion department. NUMBER FIXTURE OR ITEM Q FEE FOCALITY I
1 WATER CLOSET
Date App I iqo nt NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 6 CROSS ST.
COMPENSATION INSURANCE SHOWER 6 /1�( OWNERAL
(This section need not be completed if the work Involved by V MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this nf
permit is issued,I shall not employ any person in any manner, SINK CITY l / TEL.
so as to become subject to the Workers'Compensation Laws.LJ DISHWASHER I
/ CONTRACTOR
PA
Date(ld� A Applicant CLOTHES WASHER ADDRESS
11—
NOTICE TO APPLICANT: If, after making this Cer ficate of KV
SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. I I J WATER HEATERM LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO8, R SED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 0]�
(commencing with Section 7000)of Division 3 of the.Business OUTLETS OVER . (/
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
License Number Lic. Class DATE -�—/ C
C
FINAL L
Contractor Date BY a
❑ I am exempt under Sec. � C�
B.BP.C. for this reason Plan check fee , G
Date: v
PLUMBING PERMIT ISSUING FEE$ C71 Z
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name ;2487. 1 A
I hereby affirm that I am exempt from the Contractor's License Address # 0 0 o 0 0 5
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. ,1 ° ° 4 6.5 0
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section ° ° ° 4 5 0 v
7044, Business and Professions Code). Poo
0 6 2 3 x 8 6
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction leriding 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 Permitte Date