HomeMy Public PortalAbout8606 GARIBALDI AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING P E RM I T
I t,644by affirm that I have a certificate of consent to self 76A667A _
'Insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) u
or a certified copy thereof (Sec. 3800, Lab. C.) —COUNTY OF`LOS ANGELES BUILDING AND SAFETY
PolIcy No._T�Compony
❑
Certtfied copy Is hereby furnished.
F1 Certified
APPLICANT TO RLL IN(PRINT OR TYPE) eu .
Certified copy Is filed with the county bullding Inspec-
tion department. NUMBER FIXTURE OR TfF�N p FEE10CALITY
te
Date AppllSant WATER CLOSET _-- .._ . . _. _ -. - N
CERTIFICATE OF EXEMPTION FROM WORKM' BATH TUB - ST.
COMPENSATION I NSU RANCE
(This"ctfon need not be an*eted if the work Imrohred br e
MAL
le
the permit is for ono hundred dollars(=100)or es.) LAVATORY ADDRESS
) certify thQf-In the performance of the work for which this
permit Is Issued, I shall not employ any Person In any manner SINK CITY;. Tq
so as to become subject to the Work Co p*nsatlon Laws.
a
CONTRACTOR
Date - IIcant QOTHES WASHER ADDRESS
NOTICE TO. APPLICANT: If, after mpking Is Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Cri-Y TEL NO
Compensation provJsfors of the Labor.Code, you must forth- LAWN SPRWKLER SYSTEMwith comply with Duch provisions or this permit,shall be STATE' LIC
deemed revoked. WATER HEATER DCJ3M NO. CLASS
LICENSED CONTRACTORS DECLARATION _ DISTRICT NO• '�/ BY
I hereby affirm that t am licensed under provisions of Chapter 9 GAS SYSTEM OURETS 410
L //A.
(commencing with Section 7Q00) of Division 3 of the Business OUTLETS OVER [V/VU
and Professions Cade,and my license is In full force and effect. s PER SYSTEM DNAAL ^� LIDATION
License Number Llc. Class
TE
FI
Contractor Date BY
❑ I am exempt under Sec. AL 0
B.BP.C. for this reason Plan check fee —
Dote:
PLUMBING_PERMrr4SSUING FEE j - - 61 Q 2 A Z
Signature # o 0 o o.0 5
TOTAL FEE .1 a - 4(150
Plan check applicant
SINGLE FAMILY o 0 0 4 Q 5 0
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractors License Address - 1 224-86
Law for the following reason (Section 7031.5, Business and
Rr Ions Code): City Tel. No.
owner of the property, will do the work and the
structure Is not Intended or offered for solo (Section'
7041, Business and Professions Code
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit Is Issued -
(Sec.3097, Civ. C.). kyr
Lenders Name �17Lfr L��%`��A✓ � i _ _
Lenders Address
I certify
bove Information that I have roodcthis application aand state that the
agreecomply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize reprelentativas of thls County to enter upon the
abo e-mentioned property for lnspecilon purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Ignatur of Permittee Date