HomeMy Public PortalAbout9534 BOGUE ST_Plumbing__ WORKER'S COMPENSATIONON 720-0026 6A667A DPW 9/89 APPLICATION FOR PLUMBING PERMIT
1y 76A667
I hereby affirm that I have a certificate of conse:,t to self insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec 3800 Lab.
Company COUNTY OF LOS ANGb. C) -
1SLELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
Policy No '�
❑ Certified copy is hereby furnished.
/ _ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ��� U
M Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY
Date 10-1 -9.1 Applicant� S �t "n,)1t/lta WATER CLOSET
NEAREST
CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB
COMPENSATION INSURANCE ASSESSOR
/ MAP BOOK PAGE PARCEL
(This section need not be completed if the work involved by the SHOWER
permit is for one hundred dollars($100)or•less.) LAVATORY OWNER
I certify that in the performance of the work for which this permit
is issued, I shall not employ an person in an manner so as to MAIL i C/ �� )
P Y Y P Y SINK ADDRESS _
become subject to the Workers'Compensation Laws.
DISWASHER CITY ^ TEL.NO.
Date Applicant CLOTHES WASHER CONTRACTOR + /J
NOTICE TO APPLICANT. If, after making this Certificate of O/tJs /� ,
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS &YQS provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM / or
-
LICENSED CONTRACTORS DECLARATION CITY Y/i� TEL NO. �-
I hereby affiFm that I am licensed under provisions of Chapter 9 WATER HEATER q STATE LIC O
(commencing with Section 7000) of Division 3 of the Business and LICENSE NO �7 S CLASS
Professions Code, and my license is in full force and effect. GAS SYSTEM OUTLETS V
OUTLETS OVER �DISTRICT NO. PROCESSED BY O
c^ 5 PER SYSTEM b O
License Number n _�T Lic.ClassFINAL
DATE I—
, VALIDATION W
Contractor Date
+S IT DATE
��.1 � I �
❑ FINAL J Z
lam exempt under Sec. BY /
B&P.0 for this reason
Plan check fee ,
' Date:
PLUMBING PERMIT ISSUING FEE$ �`
Signature
TOTAL FEE sp
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name %4;(_ •=
I hereby affirm that I am exempt from the Contractor's License Law a °
for the following reason (Section 7031 5, Business and Professions Address
Code)-, ^(s
r City Tel.No.
ElI, as owner of the property,will do the work and the structure `f tD
is not intended or offered for sale (Section 7044, Business f„y' --C1 50
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 Opp.information is correct I agree to comply with all County ordinances
and State laws regulating Plumbing, and hereby authorize
t
representatives of this County to enter upon the above-mentioned
propert;�for inspect• n p jrpposes. SEE REVERSE FOR EXPLANATORY LANGUAGE