HomeMy Public PortalAbout9925 BOGUE ST_Plumbing__ ' WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby a4firm 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 certified copy thereof (Sec. 3800, Lab. C.) _��" COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. O U Company f/4� r�•�I)
Certified copy is hereby furnished.
17FOR APPLICANT TO FILL IN-(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS
NUMBER FIXTURE OR ITEM @ FEE LOCALITY
tion/de art ent. /�''``
Date `� Applicant (li�1 rI► �_ WATER CLOSET Q41� e) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB r-i CROSS ST.
COMPENSATION INSURANCE SHOWER !/ OWNER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) 2, LAVATORY ADDRESS 2S6W&CS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY `J L G/? TEL. NO.
so as to become subject to the Workers Compensation Laws. DISHWASHER OI_/ I 1
NTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
ZV
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM ;CITY TEL. NO. ^� Z
with comply with such provisions or this permit shall be STATE LIC. Q
deemed revoked. WATER HEATER LICENSE NO. b Z CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
op
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER J -C�_z
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION Oo�
License Number 6 )- DATE Lic. Class — 0,
r , FINAL
Contractor 7/��( CK �y Date BY Q
❑ I am exempt under Sec.
B.BP.C. for this reason
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ C
Signature
TOTAL FEE
SINGLE FAMILY
Plan check applicant
_
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address N-1 `"T
Law for the following reason (Section 7031.5, Business and —».-
Professions Code): City Tel. No. }t
❑ 1, as owner of the property, will do the work and the }t`.
structure is not intended or offered for sale (Section ;»�
7044, Business and Professions Code). `6'L -_3•.0
CONSTRUCTION LENDING AGENCY 'CH�i_€i t,. (!
I hereby affirm that there is a construction lending agency forr,,,,- _ .
the performance of the work for which this permit is issued 1.Hi'NGE ,ti{j
(Sec. 3097, Civ. C.).
Lender's Name. l
»t s a w ;-
Lender's Address
1 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 Permittee Date