HomeMy Public PortalAbout9842 FLAHERTY ST_Plumbing__ WORKER'S COMPENSATION DECLARATION 20-0026 DPW 9189 APPLICATION FOR PLUMBING PERMIT
76A667A
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.C.)
t� COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
Policy No.z 2 9-'S j 3 9 Company _57;9725 �`(//Y/!)
❑ Certified copy is hereby furnished. BUILDING j
F] FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS ✓J - � Py
Certified copy is filed with the county building inspection
�7departt/ment. �/ NUMBER FIXTURE OR ITEM @ FEE
Date /-1/ -25 Applicant Zf�y S47-m-". LOCALITY
pp WATER CLOSET16,5_6, NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
Z BATH TUBI jU ASSESSOR 1 //
COMPENSATION INSURANCE MAP BOOK � f' PAGE (C PARCEL&O
(This section need not be completed if the work involved by the Z SHOWER �� �0
19
permit is for one hundred dollars($100)or less.) OWNER
I certify that in the performance of the work for which this permit s LAVATORY
is issued, I shall not employ any person in any manner so as toMAIL 61,
Z SINK - 0 Q ADDRESS
become subject to the Workers' Compensation Laws.
DISWASHER CITY TEL.NO.
Date Applicant / CLOTHES WASHERCONTRACTOR
NOTICE TO APPLICANT: It, after making this Certificate of Z,5t22
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS r! /
provisions of the Labor Cade, you must forthwith comply with such 7Y7 y 5, V 1 f!• Sox
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO.�_ S a-
I hereby affirm that I am licensed under provisions of Chapter 9 f WATER HEATER d /C /1�f Z'f3-LSf 0
(commencing with Section 7000) of Division 3 of the Business and GAS SYSTEM OUTLETS LICE SE NO. ,j ZO_5- o CLASS
Professions Code, and my license is in full force and effect.
OUTLETS OVER `�oFj D DISTRICT NO. PROCESSED BY
5 PER SYSTEM
License Number 52-0 S VO Lic.Class ��
S �3"osc �f� I--
_ - FINAL �� �-y� - VALIDATION
DATE
Contractor Date �
❑ FINAL " M«,.J _ ,o a I i
I am exempt under Sec. BY ! `
B.&P.C.for this reason {s^l=_
Plan check fee --• —� s
Date: 01111'. __... •2 �'mak' � --0
Signature PLUMBING PERMIT ISSUING FEE$ ' .
� C-1 -74.
,
'_• 1=_•
TOTAL FEE !�/ �� ^
El
13F= I=s=
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law y__;Sg—_ 4M:i t;'1$;';•'_
for the following reason (Section 7031.5, Business and Professions Address
Code): ;;-t 1 _ { N 1120113 12011 I
❑ City Tel. No.
I, 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). ,
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.) 7,��/)
Lender's Name� O��C
Lender's Address
I 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
propert for inspection purpos SEE REVERSE FOR EXPLANATORY LANGUAGE
O401-
natufdsof Permittee Date