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HomeMy Public PortalAbout4521 ELLIS LN_Plumbing__ WORKERS"COMPENSATION DECLARATION APP IC n IWN FOR PLUMBING PERMIT I hereby, affirm that I have a certificate of consent to self in- 76A66�A PW 490 G�1 IJ CJ" ©lNfl UPJ sure,or a c%rtificate of Workers'Compensation Insurance,ora ceit`fie'd copy thereof (Sec. 3800, Lab S ^� Company COUNTY,OF Lot ANGELES' DEPT,. OF PUBLIC WORKS Policy No Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspection. ADDRESS — 'department. NUMBER FIXTURE OR ITEM @ FEE // p LOCALITY SDG _. Date-1 ``_`'— L APPlicanT /'7�'C� '� WATER CLOSET.(TOILET) �l� �� NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER r R) ✓ � i� �'�'- (This section need not be completed if the work involved by MAIL J� the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS I certify that in the performance of the,work forwhich this per- mit is issued, I shall not employ an erson.in an manner so SINK CITY Pl. Gy TEL. NO. 7 t1 . P Y Y P Y �-- �'' L��E". to become subject to the Workers'Compensation Laws., DISHWASHER IW as - CONTRACTOR /� Date Applicant CLOTHES.WASHER -�✓. �. ADDRESS NOTICE TO,APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the`Workers'.Compen- CITYi TEL. N sation provisions of the Labor Code,'.you,must forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok- STATE G UC. i ed. WATER HEATER' LICENSE NO. Z� p Z� CLASS LICENSED.CONTRACTORS DECLARATION.• DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM 'OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION feet. ZZZS HOSE BIB DATE I 2 -v� 00 License Number Lic..ClassC. FINAL. O it,, iCZ 3'i U Contractor b '�y � Date IBY O. 0 .I am exempt under,Sec. U B.BP.C, for this reason PIan.CheCk-fee - d N Date: PLUMBING PERMIT ISSUING FEE$ �� Q Z Signature TOTAL FEE �b. SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name. Law for the following reason (Section 7.031:5,:Business'andACCToA ' Professions Code): 'Address 1503 43.40 I, as owner of the property, will do the-work and the City; Tel. No. 1 ITEMS ' structure is not intended or offered forsole(Section 7044; Business and Professions Code): ® TOTAL 43-40 CONSTRUCTION LENDING AGENCY. CHECK ljzlp I hereby affirm that there is a construction lending agency for rr the performance of the work'fair which this permit is'issued CHANGE .00 (Sec. 3097, Civ. C.) Lender's Name 0000`0001 6/13/96 Lender's Address 6880 1 ' AM 8,.14 I certify that.1 hove read this application and 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 abo e-mentioned pcoperty.for inspection purposes. L SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date