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Home My Public Portal About9994 BOGUE ST_Plumbing__ i�WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I heyJby affirm that I have a certificate of consent to self 76A667A r—►Y r �.r 6deCe6a PERMIT A 5nsure, or a certificate of Workers' Compensation'lnsurance, CE 817(REV 10/81) ors a certified copy thereof (Sec. 3800, Lab 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 �� ' F]' Certified copy is filed with the county building inspec- ADDRESS tion department. NUMBER , FIXTURE OR ITEM @ FEE p LOCALITY 'Em�'Ef. Date Appligant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION-FROM WORKERS' BATH TUB © W,,ive�' Oil) CROSS ST. COMPENSATION INSURANCE h OWNER �� •J�� (This section need not be completed if the work involved by SHOWER V D the permit is for one hundred dollars $100 or less. MAIL \ P ( LAVATORY ADDRESS_ /AQ+j✓� J I certify that in the performance:of the work for which this permit is issued, I shall-not employ any person in any manner SINK CITY i; TEL. NOa so as to become subject to the Workers Compensation Laws DISHWASHER d d /J CONTRACTOR v Dat 4, App I16.n C�• ►� CLOTHES WASHER ADDRESS NOTICE TO APPLICANT- If, after making this Certificate SWIMMING POOL RECEPTOR Exemption, you should become subject to the Work s' Compensation provisions of the Labor Code, you must forth- CITY TEL NO, LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall.be STATE LIC deemed revoked. WATER HEATER LICENSE NO, CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO PR E D BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER c D, and Professions Code,and my license is in full force and effect. SPER_ SYSTEM J T DAL VALIDATIO License Number Lic. Class sC �1' C�� y FIN Contractor Date BY 0 I am exempt under Sec B.BP C. for this reason ► Z Plan check fee �4 1 3,9 A Date- PLUMBING PERMIT ISSUING FEE$ Signature # 0 6 0 0 0 5 TOTAL FEE Plan check applicant ( ° ° 40.50 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name ' ° °-° 4 Q 5 0 5 I hereby affirm that I am exempt from the Contractor's License Address O 228-- 86 Law for the following reason (Section 7031.5, Business and Prof ssions Code) City Tel No.' 1, as owner of the property, will do the work and the structure is not intended or offered for sale (Section , 7044, Business 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.). ` '•, r 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 ab ve-mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Per ittee Date