HomeMy Public PortalAbout4924 FIESTA AVE_Plumbing__ IJ WORKERS'COMPENSATION DECLARATION APPLICATION FORPLUMBIN PERMIT
I hereby affirm that I have a certificate of consent to self .76A667A.
insure, or a certificate of Workers, Compensation Insurance, CE 817(REV. 10/8)) u
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES _ _BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished.
F1 Certified
APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING A h�
Certified copy is filed with the county building inspec- ADDRESS lg<S-TA v
tion department. NUMBER FIXTURE OR ITEM a FEE �
LOCALITY
Date Applicant l WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER � '� —i
(This section need not be completed if the work involved by MAIL nc AA,,�
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS 7� r7Td ��1i
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITYA TEL. NO.
so as to become.subject to the Workers'Compensation Laws. DISHWASHER
tf CONTRACTOR
Date 1/� Applicav - CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this C ificat o SWIMMING POOL RECEPTOR
Exemption, you should become subject to the WorkersCITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE "' LIC.
deemed revoked. WATER HEATER LICENSE NO.
LICENSED CONTRACTORS DECLARATION DISTRICT NO. P CESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM , OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER D�
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
DATE O
License Number Lic. Class
FINAL' U
Contractor Date BY
I am exempt under Sec.
O
B.&P.C. for this reason U
Plan check fee ® w
a
Date: PLUMBING PERMIT ISSUING FEE$ U Z
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant 1m, (ch QQ t
HOME OWNER-BUILDER DECLARATION Namer,`eg;6,C-L_ , Lt ArgJ-eLn
1 hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and AddressZ A►�
Professions Code): City ` Tel. No.(M) I ,
1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code). 2 5 9 3.7 A
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for # 0 0 0 0 0 5
the performance of the work for which this permit is issued 1 0 0 2 8 5 0
(Sec. 3097, Civ. C.).
Lender's Name a - o2&505
Lender's Address 11,,14-86
1 certify that I have 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
above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY-LANGUAGE
Signoture of e",mitleeDate