HomeMy Public PortalAbout9560 BISBY ST_Plumbing__ WORIIRS'COMPS SAnON MCLAR°n°N APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have 8 certlflcaflbnflf'cnt to self 7��q
'-"inilure, dr a certificate of Workers' Compensation 12surance, CE 817(REV. 10/81)
or a certified o thereof (Sec. 3800, Lab• C-) COUNTY OF LOS ANGELES WILDING AND SAFETY
Policy NCompany
❑ Certtfted copy Is hereby fumished.
® Certified copy is filed with the coun building Inspec- FOR APPXTUROR
RLL IN(PRINT OR TYPE) l;
tlbn ent. NUMBER FIXTURE OR ITEMO FEE LOCALITY
WATER CIGSET
Date Applicant f �16 !T r
CERTIFICATE OF D(EM.VRON FROM WORKERS' BAT}i TUB
COMPENSATION INSURANCE 01IVl"
(This section need not be complefed if the work 1. volved byADL �[� L
the permit 1s forone hundred dollars ($100)or less.) LAVATORY ADDRESS
1 certify that In the performance of tke work for which this
permit Is Issued, I shall not employ aay Person In any/manner SINK `ry G( T TEL 1104461 S�C_
so as to become subject to the Workers Compensation Laws. DI51(WASHEROONTRCTOR T
�c
Date AT+ IIcant CLOTHES WASHER ADDRESS rDy S
NOTICE TO APPLrANT: If, after making thl; Certificate of SWL MAING POOL TOR 'a
Exemption, you should become subject to the Workers' TEL.. NO
Compensatlon provisions of*w Labor Code, you must forth- LAWN MRINCLER SYSTEM
with comply with such provisions or this permit shall be STATE LAC S�
deemed revoked.. WATER HEATER I� CLASS ,
LICENSED CONTRACTORS DECLARATION D1:STRr_7 INK) BY
I hereby affirm that I am licensed under provisions of Chapter 9 CSS SYSTEM OUTLETS
(commencing with Section 70DO)of Division 3 of tf» Business OUTLETS OVER C
and ProfeesIone Code,and my license to M full force and effect. 5 PER SYSTEM FINAL VA ATION
DATE
License Number � c. Class
FI QQ
Contractor Date BY
❑ I am exempt under Sec
B.BP.C. for this reason Plan check fee R 49 aw
Date: U)
PLUMBING PERMIT ISSUING FEE$ # o 0 0 0 0 5
EZ
Signature —`
TOTnLf E A o,o4650
' Plan check applicant
SINGLE FAMILY 0.9 0 4 6506
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from fFm Contractoes License Address 0 7.0 9 i 8 6
Law fW the following reason (Section 7031.5, Business and
Profesalbrn 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, Busingss and Professions Code).
CONSTRLK70N LENDING AGENCY
I her affirm that there Is a construction lending agency for
the performance of the work for which this permit Is Issued
(Sec. 3097, Cly. C.).
Lender'f Name
Lenders Address
I certify that I have read this application and state that the ,
above Information Is correct. I agree t9 comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize reprelentatives of this County to enter upon the
above-m tion party for Inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE _
Signature P 'Ifttear Date
Lam- /