HomeMy Public PortalAbout9435 DAINES DR_Plumbing__ WORKERS' COMPENSATION DECLARATION APPUCA ll�50H FOR PLUMBING PERMOT
I hereby gffirm'that I have a certificate of consent to self 20-0026 DPW 6/87.
n
iure, or a c6rtificate of Workers"Compensation Insurance, 76A667A , ' ,- j'JI
or a-certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Policy No. Company"
D Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified`copy.is filed with The county building inspec- ADDRESS G
tion department. NUMBER FIXTURE OR ITEM ?n FEE LOCALITY
WATER CLOSET AQ
Date Applicant NEAREST_
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB D CROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER
MAIL
the permit4s for one hundred dollars($100)or less.) LAVATORY ADDRESS -[ S t r3 171�� Jr
I certify that in the performance of the work for which this
permit is issued, I shall hot employ any person in.an manner. ��SINK CITY. TIL.,N 1
so as to become subject to the Workers'Compensation Laws. Ci
DISHWASHER CONTRACTOR e4
Date Applicant. CLOTHESWASHER
ADDRESS
NOTICE TO APPLICANT: If, after'making this Certificate of '
SWIMMING POOL RECEPTOR
Exemption, ybu should become subject, to the Workers'
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL. NO:
with comply with such- provisions or this permit shall be STATE LIC,
deemed revoked. WATER HEATERLICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION b DISTRICT NO. O D BY
+�
I hereby affirm that I am licensed under provisions of Chapter 9 � GAS SYSTEM OUTLETS � d 65
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINALVA I®ATIOV�I a:
DATE . C Z— rL 0
License Number Lic. Class V.
FINAL
Contractor Date BY Q'
❑ I am exempt under Sec. 0�,
B.&P.C. for this reason A'
Plan check fee
Date: -Z) >
PLUMBING*
ate: PLUMBING*PERMIT ISSUING FEE$
Signature -
TOTALFEE Q
Plan check applicant
SINGLE FAMILY °f
HOMEOWNER-BUILDER DECLARATION Name .;
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and - Address
Ell"
Code): City Tel. No.
ElI, as owner of the property, will do the work and the
structure is not intended or offered for sale Section `e
7044, Business and Professions Code).
I
::•
CONSTRUCTION LENDING,AGENCY " `J
Y L 1
I hereby off irm 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 if 1J4�-f j r!l a ,
„ i
Lender's Address
I certify that I have read this application and state that the D
above information is correct. I agree.to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned'property,for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o ittee Date