HomeMy Public PortalAbout10214 DAINES DR_Plumbing__ ' 'VOORKERS' COMPENSATION DECLARATION 'APPLICATION FOR PLUMBING PERMIT
I hereby affirm 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 Company
' Certified copy is hereby furnished BUILDING
' FOR APPLICANT TO FILL IN(PRINT OR TYPE)' ADDRESS
Certified copy is filed with the county building inspec-
tion department NUMBER FIXTURE OR ITEM @ FEE
F LOCALITY � G
WATER CLOSET
Date Appli4ant ) O0 NEARESY;,;
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST,'
COMPENSATION INSURANCE OWNER r` e* LA,,V
(This section need not be completed If the work Involved by SHOWER
the permit Is for one hundred dollars $100 or lest. MAIL
p ( ) ) LAVATORY ( ADDRESS b Z / Q A I ME-S
I certify that in the performance of the*work for which this
permit is issued, I shall not employ any person in any manner SINK CITY G _ TEL NO
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR Z
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT-.If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL NO
with comply with such provisions or this permit shall be STATE L LIC
deemed revoked WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO ROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS O
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is to full force and effect 5 PER SYSTEM FINA VALIDATION a
DATE O,
License Number XJ Lic Class
V,
��j, FI L a'
Contractor Lo Date `—Z f- B 0.
❑' I am exempt under Sec I W
B 6P C for this reason ELI
Plan check fee N
DateZ
PLUMBING PERMIT ISSUING FEE$ 0
Signature �1 .
TOTAL FEE , V
SINGLE FAMILY
Plan check applicant
. �
HOME OWNER-BUILDER DECLARATION -Name �
I hereby affirm that I am exempt from the Contractor's License Address Ajar
Law for the following reason (Section 7031 5, Business and .�
Professions Code) City Tel No 3307 ,AJ
❑ 1, as owner of the property, will do the work and the 1 IIM
structure is not intended or offered for sale (Section
7044, Business and Professions Code) ® TOTAL 28.50
CONSTRUCTION LENDING AGENCY MCK 28.51[I
I hereby affirm that there is a construction lending agency for "
the performance of the work for which this permit is issued 4H •00
'(Sec 3097, Civ C ) ;
Lender's Name ,
. 5/24/89
Lender's Address -;Lee 1 'AM lf 9:01
.I certify that I have read this application and state that the , JTG7 L
above information is correct I agree to comply with all County
ordinances and State laws regulating lumbing, and hereby
authorize representatives of this C nt to enter upon,the
above-mentioned property for i cti purposes
SEE REVERSE FOR EXPLANATORY1ANGUAGE
Signature ee Date