HomeMy Public PortalAbout10819 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' Compensation Insurance, 76A667A
or a certified o y thereofc 38 b/.JC�) (np� �^ COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No � c E$MID y � l/yl �►1,{//n �ca,
❑ 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 @ FEE
dept�aLOCALITY
���/� Q( J WATER CLOSET ,
Date_11_f�L�LApplican �� NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB /6 CROSS ST.
COMPENSATION INSURANCEg OWNER el
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars $100 or less. v MAIL
p ( ) ) LAVATORY �'� ADDRESS
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
,djO CONTRALTO
Date Applicant CLOTHES WASHER Z ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY C TEL. NO.o-�l�
LAWN SPRINKLER SYSTEM J
with comply with such provisions or this permit shall be STAT LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROLE D BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER ��
and Professions Code,and m license is in full force and effect. 5 PER SYSTEM
y _ //
1, 1.,
1-1-1,
1, VALIDATION
License Nu ber �Lic. Class go � •� C-A.
' FINAL
Contracto BY
❑ I am exempt under Sec. �
bel'
B.BP.C. for this reason Pian check fee 100. B�lD9
Date:
PLUMBING PERMIT ISSUING FEE$ /_3
Signature 1/0
TOTAL FEE 1136100
Plan check applicant
SINGLE FAMILY -
HOME OWNER-BUILDER DECLARATION Name '•
I hereby affirm that I am exempt from the Contractor's LicenseAddress H ''-' °'s'
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. 3,31J4_i:�� L•
❑ I, as owner of the property, will do the work and the _ .i�~01S
structure is not intended or offered for sale (Section TOTAL
e��''pp
.,r h r { -5
° Ii_2 kms'
7044, Business and Professions Code). ® (t{i y� ,� „�
CONSTRUCTION LENDING AGENCY "'HED,
I hereby affirm that there is a construction lending agency for i`"'
the performance of the work for which this permit is issued i_HANGEr_AI
(Sec. 3097, Civ. C.).
Lender's Name
13411 i!1-'I�( 1�� i?'i.::::.•`.'a
Lender's'"act =~�
I certi at I have read this application and state that the
ob ve information is correct. I agree t comply with all County
or ces and State laws regulati Plumbing, and hereby
authorize resentatives of this o my to enter upon the
above-mentio ed property for ins ee ion purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
�MI
Signature of Permittee__) Date