HomeMy Public PortalAbout9832 DAINES DR_Plumbing__ WbRKERS'COMPENSATION DECLARATION 7GA667A A P P L I C A T I O/N F O P ^U M B I N G PERMIT
I.hereby.3tffirm that I have a certificate of consent to self �e e» (z-ao)
insure, or a certificate of Workers'Compensation Insurance,or l
a certified copy thereof(Sec 3800, Lab C.)
COUNTY OF LO ANGE S BUILDING AND"SAFETY
Policy No Company
Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING �)
ADDRESS ,2—
.Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM FEE
department LOCALITY
_ WATER CLOSET
Date Applicant NEAREST
BATH TUB CROSS ST �,(J
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved LAVATORY MAILADDRESS
by the•permit Js for one hundred dollars ($100) or less.) SINK CITY �' TEL N O CL
26-S71 719 0
I certify that in the performan of th � ork for which t is DISHWASHER 0
permit is issued, I shall not pl a person m any m er CONTRACTOR .1
so as to become subject to
pal
pe aws CLOTHES WASHER ADDRESS` 0
Date -j/1 Applicant SWIMMING POOL RECEPTOR 0
NOTICE TO APPLICA If, after making this Certificate of CITY• TEL NO W
W
Exemption,' you sh d become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC
Compensation provisions of the Labor Code, you must forth- LICENSE NO CLASS Z
with comply with such provisions or this permit shall be WATER HEATER
�
deemed revoked. r GAS SYSTEM' OUTLETS DISTRICT PR ESSE B
LICENSED'CONTRACTORS DECLARATION OUTLETS OVER S U
I hereby affirm that 1 am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL VALIDATION
ness and Professions Code, and my license is in full force and DATE
effect.,
License Number Lic Class FINAL
BY � s4
Contractor Date
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or,a registered',professional engineer
acting in iffy professional capacity (Section 7051, Bus-
PLUMBING PERMIT ISSUING FEE$
iness and Professions�Code)J TOTAL FEE
Lic.or Reg.No Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name v _
I hereby affirm that I am exempt from the Contractor's Address
License Law for the following reason (Section 7031.5, Busi- Fly Tel, No.-
ness and Professions Code)
F1I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project 9 1 7 a.'5 A
(Section 7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY # 0'0 0.0 0 5
I hereby affirm that there is a construction lending agency 2 0 0 1 0,00
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.) o'o 0 1 0.0 0 v
Lender's Name
Lender's Address 0815 1-80
I certify that I have read this application and state that the
above information is correct I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances an State laws reVrpe,tion
'ng Plumbing, and hereby
au �entativesounty to enter upon the
purposes
Signature of Permittee Date