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Home My Public Portal About10640 DAINES DR_Plumbing__ WORKERS' COMPENSATION DECLARATION - APPLICATION FOR PLUMBING �I:R61flIT. hecgby, offir'm that have.d certificate of consent to self m �6A66�A PW d!Bi sua„ora certificate o{Workers Compensation Insurance,pro CE 817 (REV, 3/86) .certified copy, thereof (Sec 3800, Lab C J _ .•^ 7 COUNTY OF*LOS ANGELES .'DEPT`OF`PUBLIC WORKS - Policy No •Company ' �'k .-. A: 17 Certified copy is hereby furnished: y FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspection - ADDRESS NUMBER FIXTURE OR.ITEM' FEE 0.._department. -� _. `@ LOCALITY - - WATER CLOSET(TOILET) DO - Date - Applicant, - NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' - �j , BATH TUB D© CROSS 57' - COMPENSATION INSURANCE (This section need not.he compleeed if the,work:involved by SHOWER- .: MAR �M.j` . �� . the permit is'for one hundred dollars ($100) or less:) LAVATORYADDRF55 /S'�C /olp0 VO I cIetify that in�the performance of the work for which this.per- SINK ' MIT is issued, I sholl'nat employ any persomin any manner So - 'CITY . LE T' TEL. NO. _ H 0 as to"become subject o the Workers' Compensation Laws. DISHWASHER • _ G Y d t - `��+'` (� , CONTRACTOR � Y Date._U47� Applicant , ' CLOTHES'WASHER 0o - NOTICE TO APPLICANT: If,ditermaking this Carti is e o Ex- .. ADDRESS amp tion,you'shoutd:become subject to the Workers'Compen- SWIMMING POOL RECEPTOR , - CITY TEL NO- "sdtion provisions of the Labor Code;you most forthwith comp- LAW N,BPRINKLER SYSTEM y with such provisions of this permit shall be deemed revok- STATE LIC. WATER HEATER r _�O LICENSE NO. - 'CLASS LICENSED CONTRACTORS DECLARATION' • .'. VJ DISTRICT NO. PROCESSED BY Lhereliy affirm that I am licensed under provisions oLChapter GAS.SYSTEM OUTLETS S� 9:(commencing with Section 7000)of Division 3 of the Business - OUTLETS OVER • - and Professions Code, and my license is in full force and ef- S.PER SYSTEM FINAL VALIDATION Y feet... ' - - DATE M License Number � Lie Class - - O i U Contractor Date s - BY / F. I am-exempt under Sec.. - W I a r t B.BP.C, for this reason - - D - Z Plan check fee - _ Date: .'PLUMBING PERMIT ISSUING FEE$ SO , Signature ' .. _ .. TOTAL FEE SINGLE,FAMILY HOMEOWNER-BUILDER DECLARATION .Plan check applicant " I hereby affirm that I am exempt.from the Contractor's License Name - 9 7�Q 3 A Law for the following reason (Section 7031'.5, Business and Professions Code): - Address - - - - #"ee'�:a o,5 1, os owner,of the property, will do the work and the City ._Tel. No. - - .I • • 825.0 structure isnot intended or offered for sale(Section 7044,. _ _ 'e e's 8 2 5 0.� Business•and,Professions'Code). - ' CONSTRUCTION LENDING AGENCY 1 _ - D 2 6�.$•8 fhereby affirm thbt.there is a construction,lending agency for - - the performance of the work for 'which this permit is issued - - - (Sec: 3097, Giv. C.). v.... - Lender's Name lender's Address .I, - 4'. I certify that.I have read this application ond''s}ate that the - - - above information is correct. I agree to comply with all County D, ' ordinances and State laws regulating Plumbing,-and hereby - - - authorize,-representatives of this County to enter upon the - obove=mentioned,property for inspe<tiompurposes. 57"`�J' SEE REVERSE-FOR EXPLANATORY LANGUAGE Sign Lure of Per itte, 'Dat !, - _ .