HomeMy Public PortalAbout9162 FORTSON DR_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION* FOR PLUMBING PERMIT
• 20-0026 DPW 4/90
a hereby,�aft cm that d;have,a certificate of consent to self in- 76A667A
suse,'or a certificate of Workers'Compensation Insurance,c r a
certified copy thereof (Sec. 3000, Lab. C.
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified.copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING // ^ /�� Lni 1. y1n
F] Certified copy is filed with the county building inspection ADDRESS `��" L /'(/ 1!5C / A��r[
NUMBER FIXTURE OR ITLM LOCALITY -7r
WATER CLOSET
department _ @ FEE
(TOILET)
Date Applicant . NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' / � )BATH-TUB CROSS ST L d
COMPENSATION INSURANCE SHOWER OWNER _; 51 N CqA
(This section need not be completed if the work involved by MAIL1
the permit is for one hundred dollars ($100)•or less.) LAVATORY ADDRESS iFW
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so SINK CITY ,`fVgk,6 C'7YTEL. NO _r
as to become subject to the Workers'Compensation Laws DISHWASHER
CONTRACTOR
Date qa' .—Applicant �/}� '`�71�A"Y–J4 ` CLOTHES WASHER ADDRESS •
NOTIC TO PPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you,should become subject to the Workers'Com pen: CITY TEL NO.
sation provisions'of the Labor Code, you must-forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PR SED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALI TION
fect HOSE BIB DATE
•License Number _ Lic. Class a
FINAL O
Contractor Date BY U
DC:
I am exempt under Sec. 0
B.&P.C:for this reason ► Wi
Plan check fee a
Date: PLUMBING PERMIT ISSUING FEE$ �7 ao
Signature
SINGLE FAMILY TOTAL FEE TIL 70- -
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 7031.5, Business and ACCUL
Professions Code)- Address
�3 •
M1, as owner of the property' , will do the work and the City Tel No. 391.70
structure is not intended or offered for sale(Section 7044, 1 ITE
Business and Professions Code). TOTAL V1.7101
CONSTRUCTION LENDING AGENCY CHECK- 91.70
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CHANGE 000
(Sec. 3097, Civ C )
Lender's Name
• 0000-0001 9/ 7/95
Lender's Address 2198 1 PCI 4:57
1 certify that I have read this application and state that th'e ,
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-mgt oned pr(erty for inspe tion purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature of Permittee ate