HomeMy Public PortalAbout9560 DAINES DR_Plumbing__ WORKERS'COMPENSATION DECLARATION 20-0026 DPW 4/90 APPLICATION FOR PLUMBING PERMIT
J hereby;affirm that I have a certificate of consent to self in- 76A667A
sure,or a certificate of Workers'Compensation Insurance,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 [ nen
FOR APPLICANT TO FILL IN(PRINT OR TYPE) _/ v 5
Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant WATER CLOSET(TOILET) NEAREST
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS Djun /o
I certify that in the performance of the work for which this per- SINK CITY �� P TEL. NO.�7�— �(a
mit is issued, I shall not employ any person in any manner so
as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen-" CITY TEL. NO.
cation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION. DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS lz:�f
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL _ \ 1,1 ATION
feet. HOSE BIB DATE o4 43.40 y.
License Number Lic. Class % Ib
FINAL _. O
Contractor Date BY Z
V
I am exempt under Sec.
U
B.BP.C. for this reason 1 ITEMS w
Plan check fee pop.
Date: PLUMBING PERMIT ISSUING FEE$ Q
Signature 43.40TOTAL FEE d
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business andCU 8/25!95
Professions Code): Address ���
I, as owner of the a.Wproperty, will do the work and the City Tel. No. 7 1 Afl1fn09
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). ,
CONSTRUCTION LENDING AGENCY
I hereby affirm 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
Lender's Address
I certify that I have read this applicationand state that.the ,
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-me 'oned pr erty for inspection purp sec.
r
' 8 1-6. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Datel