HomeMy Public PortalAbout9321 BLACKLEY ST_Plumbing__ WORKERS'LOMPENgAT���N DECLARATION
hereby'affirrh that I have a certificate of consent to self 26-0026 DPW 6/87 APPLICATION FOR PLUMBING PERMIT
insure, or a certificate of Workers' Compensation Insurance, 76A667A
or a cc!tif`i-eId copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Day ompany e
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDINGO,
Certified copy is filed with the county building inspec- ADDRESS 1 . L cek
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
�(� WATER CLOSET �i
Date Applicant T NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' 3 BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER
Da
(This section need not be completed if the work Involved by SHOWER b ,1
the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL
ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITYTEL. NO.
so as to become subject to the Workers'Compensation Laws. -Te C '
DISHWASHER O CONTRACTOR 11
1
Date Applicant CLOTHES WASHER ADDRESS, A� �
NOTICE TO APPLICANT: If, after making this Certificate of `C`t'' �,J -G
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY QV` TEL. NO. )� tC
LAWN SPRINKLER SYSTEM �-U
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. I WATER HEATER LICENSE NO. P-7 CLASS 5LD4C-4
LICENSED CONTRACTORS DECLARATION DIS TRIC NO. ROCESSED
I hereby affirm that I am licensed under provisions of Chapter 9 I GAS SYSTEM OUTLETS 5 O (/
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER a
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL PN
C3(o LIDAT ON
License Number Lic. Class G DAT �• r�
U.
tt,,�� + 2 ( FINAL
v
Contractor Ptl6Rde1IPe1Uvr�6;A61 to -3J T_ ` BY 0'
❑ I am exempt under Sec. �J
B.BP.C. for this reason
Plan check fee ® �
Date: PLUMBING PERMIT ISSUING FEE$ 13
Signature -
TOTAL FEE
Plan check applicant 3307. 141i15l
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name j I T IENwi,
I hereby affirm that I am exempt from the Contractor's License I
Law for the following reason (Section 7031.5, Business and Address TOTAL AL =
50
Professions Code): City Tel. No. t".HECK 1il0.51�
❑ 1, as owner of the property, will do the work and the ""H ANGE eL[lf
structure is not intended or offered for sale (Section
7044, Business and Professions Code). poll
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for1-)�'1-) —i-)(�(-If =/14.` 0
the performance of the work for which.this permit is issued lr � Idrrs
(Sec. 3097, Civ. C.).
r
Lender's Name i C
Lender's Address P- � 3
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
45i�
�1o�A,A( 00 ,L-a� 3-14-96
ature of P rmittee Dote