HomeMy Public PortalAbout10828 DAINES DR_Plumbing__ WORKERS'COMPENSATION DECLARATION 7GAWA APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have acertificate of consent to self ee ev (2-80)
insure_,r a.certificate of Workers'Compensation Insurance,or .. ,
a certiff Itl copy thereof(Sea 3800,Lab.C.) COUNTY OF LOS ANGELES - BUILDING AND SAFETY.
Policy No. Company
R Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS'
El Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM 0 FEE
department. LOCALITY Y
WATER CLOSET �. C
Date Applicant NEAREST _
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' - - -
COMPENSATIONINSURANCE - SHOWER OWNER lV LL
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(This section need not becomple[ed if the work involved LAVATORY. _ MAIL, ' ADDRESS /()
by the permif is for one hundred dollars ($100) or less.) SINKO
CITV�£M�LC C
I certify that in the performance-of`thework for which this DISHWASHER TEL. NO. 0/� X
permit is issued, I shall not employ any person in anv manner
CONTRACTOR we A! COAST L70 Q
so as to become subject to therSWIMMING Workers' Comp ation Laws. / CLOTHES WASHER ADDRESS U
Dat lz �'D'APPlicant 'U �
POOL RECEPTOR I Af R Arr(5 N I o �. - W
'
NOTICE TO APPLICANT: If, after making this Certificate of CITY .pZ TEL.NO.S'1/e-/ 3 �
Exemption, you should ;become subject to the Workers' LAWN SPRINKLER SYSTEM STATE - LIC. y z
Compensation provisions of the Labor Code, you must forth- LICENSE NO�d CLASS r�
with comply with such provisions or this permit shall he WATER HEATER
deemed revoked. GAS SYSTEM OUTLETSDISTRICT NO. PR ESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section:7000)of Division 3 of the Bust- FINAL /
ness and Professions Code, and my license is in full force and DATE Z VALIDATION'Z� (
effect.
ll 3 .FINAL (t'
License Nu/m16 er+�aS 2-�7.f( Lie.Class r BY
Contractor/E Date /D '2 - 9-0
ElI am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING'PERMIT ISSUING FEE$ 76-11
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). —ITOTAL FEE -�
Lie.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Address
License Law for the following reason (Section.7031.5, Busi- City Tel.No. -
ness and Professions Code):
1, as.owner oftheproperty, am exclusively contracting
with licensed contractors to construct the project
(Section 7044, Business and Professions Code). -
CONSTRUCTION LENDING AGENCY _ - - - ;92431 A
I 'hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is # ao o ero ,5 .
issued(Sec. 3097,Civ.C.). - _ ,
Lender's Name - 2 0 --2.500
Lender's Address -
. o • 2500
I certify that I have read this application and state that the I 0.02-80
_ ,.
above information is correct.I agree 4o comply with all County SEEREV REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby -
authorize representatives of this County to enter upon the
above mentioned property for inspection purposes. - -
o {-day' - /b- a- r{o
Signature of Permittee Date