HomeMy Public PortalAbout9941 GARIBALDI AVE_Plumbing__ .D A.
WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING P E RVI I T
I hereby affirm that I have a certificate of consent to self 76A667A
fnsVre, or a certificate of Workers' Eotnpensdtlon Insurante, Ct 817(REV. 10/81)
°ray tlf q tp yp t 5 f (,Set' 3800 Lab. COUNTY OF LOS ANGELES �� BUILDING AND SAFETY
� y4�NoW�Pd Company
fL��l Certified copy It hereby fUrnithed. FOR APPLI-W TO FILL IN(POINT OR TYPE) TNG
Certlfled'copy Is filed with the county bvIldlnq Iff%3ec, .'ADOREss
tion departm nt. NUMBER FIXTUREORITEM Q FEE LOWJTI
Date App ll48n WATER¢OSEr
CERTIFICATE OF EXEMPTION FROM WORKS BATH TUB CRbSi 5T. 1l�
COMPENSATION INSURANCE SHOWER OWNER
(Tho*odlon need not be co{npht*d IF the work Invot"d by
the permit Js for one hundred dollars ($100r or less.) LAVATORY MAIL `
ADDRE5S
I certify that In the perfotmpnr"e of'the work for which this
permit is Issued,I shall not employ any person Irl any manner SINK CtfY TEINO.
to as-to become sublect to the Workers'Compensation Laws. , OIS41WASwER
CONTRACTOR
Dote Applicant _ aOTNES WASHER
NOTICE TO APPLICANT: ff, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Worker' c[TY
Compensation provlsloM of the kabor Code,.you must forth- LAWN SPRINKLER SYSTEM
with comply with such provl;Iorm or this permit shall be STATE U"–
deemed
IGdeemed evoked. WATERHEATO OCIN$E NO. CLASS
LICENSED CONTRACTORS DECLARATION Dam NO. BY
I hereby affirm that Lam IIcer4ed under provisions of Chapter 9 GAS SYSTEM OUTLETS e L/
(commencing with Section 7000).af Division 3 of the BusLnem OUTLETS �
and Prbfeaslons Code,and ray license is In ful l force and effect. FINAL f
` (p (� V4UDATION 0
DATElu
License Numb le. Class ` —" GL
F I NAL O
Controcto to
4BY W
❑ I am exempt under Sec.
N
for this reason _
z
-Plan check fee
Date' PkUMBING PERMIT ISSUING Fes$ F
SlgnatUre
TOTAL fEE Q o v o o•o JJ
Plan check oppllca 2'o - 1650
SINQLE FAMILY
NOMI;OWNER-BUILbER DECLARATION Name o c % }G
I horgby affirm that I am exempt from the Contractor's Llten$a }
Law,fQr the following reason {SetYlan 703I.5, Business and 'ddre* Q 1 0 9'- R (i
Professlons Code): Gty Tel. No,
❑ I, as pwner of the property, will do the work and the
structure Is not Intended or offered fQr vale ($salon ,
7044,Business and Professions Codek
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a constructlon fending agency for
the performance of the work for which this permit Is Issued
(Sec. 3097,-Civ. C).
Lender's Name
Lender's Address
I certify that I have read this applltotlon and state that the
above,Information Is correct. I agree to comply with all County
prdlnances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upoA the
a mgntlon property 4nspectlon purposes,
SEE REVERSt FOR EXPLANATORY LANGUAGE
ifln tura of Per Ittee Date