HomeMy Public PortalAbout10526 FREER ST_Plumbing__ • WORKERS'COMPENSATION DECLARATION APPLICATION ION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate^of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensation Insurance, 76A667A
ort] certifiedwopy'thereof (Sec 3800, lab C ) COUNTY OF LOS ANGELES DEPT. OF PUBLIC'WORKS
P❑olic-No Company
Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS
tion department NUMBER FIXTURE OR ITEM Qa FEE// LOCALITY
Date Applicant WATER CLOSET J O NEAREST p--
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 0 CROSS ST �`F-/�
COMPENSATION INSURANCE SHOWER OWNER SS'
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100)or less.)
15— LAVATORY O_ ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY D TEL NO
so as to become subject to the Workers pen n Laws
n DISHWASHER O� CONTRACTC;R a
Date Q O! Applic t / CLOTHES WASHER ADDRESS �
NOTICE TO APPLICANT: If a ear m i this Certificate of
Exemption, you shout c rhe ject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisi of or Code, you must forth- LAWN SPRINKLER SYSTEM CITY
with comply with su p si ns or this permit shall be STATE (1 LI VO
deemed revoked. I WATER HEATER LICENSE NO 3oa97o CLASS A`-'
LICENSED CONTRACTORS DECLARATION J DIS`7 T N¢� ROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 / GAS SYSTEM OUTLETS � U
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER V
and Professions Code,and m license is in full force and effect 5 PER SYSTEM
Y FINAL � VALIDATION 101:1
DATE
0,'
License Number
3c� 17� Class 3 U
4 (q FINAL
Contractor & `, Date / / BY A ®;
❑ I am exempt under Sec U
W,
B.&P.C. for this reason WPlan check fee ® �.
Date.
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
SINGLE FAMILY
Plan check applicant
5 ,
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address ACCT.a
Law for the following reason (Section 7031 5, Business and ' 7 11201
Professions Code): City Tel No
❑ I, as owner of the property, will do the work and the 1 ITEMS
structure is not intended or offered for sale (Section ® TOTAL 112.50
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CKCK 112.50
1 hereby affirm that there is a construction lending agency,for
the performance of the work for which this permit is issued CHANE ,O[l
(Sec 3097,`Civ C ).
Lender's Name ; 0000—mai $/ 9/89
Lender's Address
5007 1 AM 11:1[I
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 property for ins ection purposes
SEE REVERSE FOR EXPLANATORY.LANGUAGE
Signature o er Date