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HomeMy Public PortalAbout10815 FREER ST_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION 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' Com ensation Insurance, 76A667A or a certified''cop ( ec. 380 , a . C. •� COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy-No. pony a Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 17 Certified copy is filed with the county building inspec- ADDRESS V. tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET 2.2 NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB J/ �0 CROSS ST. COMPENSATION INSURANCE /� (9 OWNER (This section need not be completed if the work involved by SHOWER the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL © L1'�J ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner 1 SINK CITY TEL. NO. so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY TEL NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT O. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 'D 7j (commencing with Section 7000) of Division 3 of the Business � OUTLETS OVER U and Professions Code,and m license is in full force and effect. 5 PER SYSTEM r Y FINAL VALIDATION /,, Z License Number � / Lic. Class 0-1(,f� DATE U. FINAL Contractor Date BY ❑ Qj I am exempt under Sec. � B.BP.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ 1-3 Q-0 Signature _ TOTAL FEE Plan check applicant SINGLE FAMILY ci HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's LicenseAddress I!3 (•I ° Low for the following reason (Section 7031.5, Business and Professions Code): ;--)7 �':_€;.I City Tel. No. `s_7•. EJI, 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). t I)HL m00 CONSTRUCTION LENDING AGENCY :pit_. 1'C ;Et_ 00. ZVL O I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued =•t;}tNGE (Sec. 3097, Civ. C.). Lender's Name Le?der's Iy that I have r ad this application and state that the ® i r information is correct. I agr e to comply with all County rdinances and State laws re ting Plumbing, and hereby a rize representatives a th County to enter upon the above- tinned property for ' spent' n purposes. �. SEE REVERSE FOR EXPLANATORY LANGUAGE dillZ0 9 of ermitte Date