HomeMy Public PortalAbout10870 FREER ST_Plumbing__ ORKERS'COMPENSATION DECLARATION APPLIGAT.ION FOR PLUMBING PERMIT
flrrp that I hov; a certlflcote of consent to seff 20-0028 DPW 8 B7
certificate of Workers'Compentatlon Insurance, 78AM7A
copy thereof (Sec. 3800, Lob.
c.) COUNTY OF LOS ANGELES DtPT.OF PUPLIC WORKS
P� Company c]larr
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o Certiflid copy Is hereby fumithed.
FOR APPllC4Nf TO HLL IN(PRINTOR TYPE) BUILDING "9 L�9,r L .
Certffled copy Is,Mad with the aunty bullding Irspeo- ADIDRESS fJ "
tion department. NUMBER FIXTURE OR ITEM O i$ LOCALITY
A•+ L-L Cr T
Date Appll4aot WATER CLOSET ONEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' TUB C
COMPEJNSATION INSURANCE SHOWER OWNIEit wr—
(Thls sec{on1 rre-ed clot be completed If the work Imrohred by
the peomlit h for dne hundredless
dollari(=loo)or .) LAVATORY (� �ADp 55531-1 S P CI 1.)+ A A'Y
I certify that m the performance of the work for which thisCITI TEL NO,�Cy Z
permit Is Issued;I shall not employ any Peron An any manner SINK
so as to become subject to the Worker Compensation Laws. {�
DaMAS7 ER ON CMACTOR � Cd(U y v IN1
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Date A..Hcont CLOTHES WASHER
NOTICE TO APPLICAM: If, after making, this Certificate of O 0-ry f55 6�/0 �/y,, �. p
$WIMN9NG POOL RECEPTOR cC� O
Exemption, you should become subject to the Wbrkenl' �, G� � �
Compensation provisions of the Lobar Code, you must forth- LAWN SPRINGER SYSTEM
with comply with such provisions or this permit }hall be ATE ,}--, LIC !
deerned revoked.. WATER HEATER LICENSE NO. �3 �f CLASS a—3 (�
LICENSE)CONTRACTORS DECLARATION PROCESSED BY
I hereby affirm-that I am Ilcerued under provlslont of Chapter 9 GAS SYSTEM
(corpmencing with Section 7000) of Dlylslon 3 of the Badness CUTLETS-OVER
aril Profewlons Code,and-mylicense is In full force and effect. 3 PER SYSTEM
FINAL,Wq/jq� VALIpATION
T Com-3
Ucbrlse Number li!B t3-1 Ic. iris DATE
E
Contract , C ` e_p • Date
7 BY
I am exempt under Sec.. �+^
B.BP.C. for this rwason ti ch�Ck fee
Dote PLUMBING PMMIT ISSUING FEE$ O
Signature
TOTAL FEE d
Plan check applicant
SINGLE fA/tfi1CY 5
HOME OWNER-BUILDER DECLARATION Name rs!
I hereby affirm that I am exempt from the Contractors Llcerge ! 1 s
Law for the foilowing reason (Section 7031.5, Builness and Acid ran 337 9T
Prof*WIcns Code): city Tel. No.
rM
❑ I, as owner of the property, will do the work and the 1
atrotture Is not intended or offered for sale-(Section TUAL 9 .50
7044, IjuslneM and Prafesslons Code). _ 'T
CONSTRUCTION LENDING AGENCY MCK 941■50
I hereby afflrrri that there Is a construction tending agency for .00the performpnce of the work for which this permit is ipsued
(Sec. 3097, Ov. C.}
Lender's Name 0000-Ml 7/19/n
Lender,AddAW 4573 1 AM11=48
I certify that 1 have read this application and state that the. ,
above Inforrrxytion Is correct. I agree to comply wUh all County
ordinances and State laws regulating Plumbing, and hereby
authorize reprel<entatives of fhls County to enter upon the
abovo- Cloned'property for sPectlon purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE ,
Signature of Permittee Date '