HomeMy Public PortalAbout9033 CALLITA ST_Plumbing__ WORKER'S COMPENSATION DECLARATION 20-0026 DPW 9/09 APPLICATION FOR PLUMBING PERMITA 67A
I hsreby affirm That I have a certificate of consent to self insure,
or a'certifica]Pf}a:of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab. C.)
e COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS - DEPT. OF PUBLIC WORKS DIV.
Policy No..Company —4� l%--�/
❑ Certified copy is hereby furnished. / —�—/��
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING d 33.
Certified copy is filed with the coun ildin inspecti ADDRESS -C4i.�-[T(.Z
de anm t. x NUMBER FIMURE'OR ITEM ® FEE LOCALITY
Date 9�- Applic Z �O WATER CLOSET TF0
j NEAREST
CERTIFICATE OF EXEMPTIO FROM WORKE 2 BATH TUB CROSS ST. s�'wtfA/J
COMPENSATION INSURANCE �� ASSESSOR p�
(This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL oa3
permit is for one hundred dollars($100)or less.) OWNER
I certify that in the performance of the work for which this permit 3 LAVATORY. �!
is issued, I shall not employ any person in any manner so as toSINK ADDRESS /MAIL 903
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became subject to the Workers'Compensation Laws. !�/ {
DISWASHER CITY TEL.NO. ✓ / fir
Date Applicant CLOTHES WASHER 'CONTRACTOR A
NOTICE TO APPLICANT: If, after making this Certificate of '"iit �•
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS ':;Z>7I/
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provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITE �� L�� TEL.NO. 309-3$2 a
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER /
(commencing with Section 7000) of Division 3 of the Business and STATE LICENSE NO. 4756w o CLASS V
Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS
OUTLETS OVER DISTRICT NO PROCESSED BY
5 PER SYSTEM Q
GGA
License Number 3 0 Lia Class 8 H
FINAL
DATE 8_ VALIDATION LU
Contra r Date N
❑ . I e exempt under Be . FINAL Z
8.8P.C.for
this reaso BY
c
Plan check fee
Signature
Date: D
PLUMBING PERMIT ISSUING FEE$ ''//
ay' cc
❑ TOTAL FEE - n .'`33 +A7 1JJ.7-r 11._
SINGLE FAMILY
Plan check applicant 4. i
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EM
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HOME OWNER-BUILDER DECLARATION Name MN �.� , C 1 ITEMS:
I hereby affirm that I em exempt from the Contractor's License Law TA•� i cc
70
for the following reason (Section 7031.5, Business and Professions Address TOTAL tAl i•1-_s m
L ,f r
Code):
Tot.N 1b 388'-7 ZZ C�HEC.Yt 1^=..II
❑ 1,as owner of the property,will do the work and the structure GRANGE .CIu
is not intended or offered for sale (Section 7044, Business
and Professions Code). D
CONSTRUCTION LENDING AGENCY IJQO,J-0001 8/21/0
I hereby affirm that there is a construction lending agency for the -
performance of the work for which this permit is issued (Sec. 3097, 5141 1 AM 8•._2
Civ. C.)
Lender's Name -
Lender's Address -
I certify that I have read this application and state that the above D
information is correct. I agree to comply with all County ordinances -
and State I s regulating Plumbing, and hereby authorize
representati s of this Cou to enter upon the above-mentioned
.pro f gins lion p o es. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIg ature of Pinfrillffaul,
8 ate -