HomeMy Public PortalAbout9995 BOGUE ST_Plumbing__ *VO
_ICOMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
j I).serPbylA{ft that I ave a certificate of consent to self 76A667A
irlsure, or a certificate of Workers' Compensation Insurance, CE 817 (REV 10/81)
or 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
❑ Certified copy is filed w th;thquy building inspec- ADDRESS E[
tion department NUMBER FIXTURE OR ITEM @ FEE +
Date��pp /1 LOCALITY
w Applicant WATER CLOSET V NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST �li fJ
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars ($100)or less.) ` LAVATORY MAIL /yr^I'!L�IJGf
AA
T`j
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK ,�� CITY TEL NO
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY /Bim) TEL NO
with comply with such provisions or this permit shall .be STATE C•��// LIC. ,r
deemed revokedWATER HEATER /.1 LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION (J DISTRICT NO ,/ CESSED B
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS OY
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER ='
0
and Professions Code,and my license is in full force and effect 5 PER SYSTEM FINAL
DATE VA DATION v
License NumberLic: Class- ✓ L
FINAV'l O
` BY /
Contractor �� ' ✓� Date U
❑ I am exempt under Sec IL
B 8P C for this reason •
�Zv Ian check fee �2967A Z
10011 Date. •
PLUMBING PERMIT ISSUING FEE$ 0 S # o 0 o o o 5
Signature
TOTAL FEE y ( 0 - 5250
Plan check applicant' _
SINGLE FAMILY 0 0 0 5.2 5 0 0
HOME OWNER-BUILDER DECLARATION Name w / �pE/�j' Q (� 2 Q—8 5
I hereby affirm that I am exempt from the Contractor's License gddress
Law for the following reason (Section 7031.5, Business and l
Professions 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 Opp,
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 ).
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 jaws regulating Plumbing, and hereby
authorizerepres motives of this County to enter upon the
above-me perty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnatur of Permittee Date