HomeMy Public PortalAbout4845 GOLDEN WEST AVE_Plumbing__ r woR)URS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hcrtlby vffTrm that I have a certificate of consent to $elf 7&,WA
Insure, or p certificate of V"efs'Compensgtlon Insurance, CE 817'(REV. 10/81)
or a �Ifif�ySec 3800, Lob. C.} COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No,.�j CoG�mpB¢�ny
IL-11 Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN.(PRINT OR TYPE) BUILDING
Certffibd copy 1s flied with the county building Inspec- ADOIRESS
tion department. NUMBER FXMJRE(:A rrEAh Q F13 /�►��yy LOCALITY
WATER CLOSET
Date App ll4a W tJEARfSf
CERTIFICATE Of ON FROM RK RS' BATH TUB D C^x055 ST.
COMPENSATION INSURANCE S, R 2 0 OWNER
(This wtHon need not be computed if the work Involved by MAIL
the permit is for oAe hundred dollars (:100)or 190.) LAVATORY ADDRESS
I certify that In the perforibonce of the work for which this
permit Is Issued, I shall not etnploy any Terson in any manner SLNIK QTY TEL NO.
w
to as to,became subject to-the Workers .Compensation Laws.
DISSHWASHM
ODNWAC7bk
D3 to Applicant =4s WA&,u ADD(f5S
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RL PTOf7
Exemption, you should becorno subject to the Workers CITY TEL- NO
Compensation prgvlslonY of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with c9mply with such psovlslons or this permlt'sholl be 6 STATEf^ r-- L1G
deemed revoked. wATM HFATIEP DCR SE NO. J CLSS
LICENSED'CONTRACTORS DECLARATION GAS SYSTEM OUTLETS D17S BY
I hereby affirm that t am Ilcensgd under provisions of Chapter 9
(comrn&ncing with Section 7000)'of Dlv(Slon 3 of the Business OU IM OVER
and Professlor#-Code,and m Ilrens4 is In full force and effect. S PER SYSTEM �
y FINAL VALI ATION V-
License Number L _Z�S Llc Class A_ DATE
7 ou
Cdntractbr Date BY G
I"am exempt Under Sec. d
$.SP.0 for this reason Plan check fee 24 1 5.7 A
Udte: PLUNMING PERMIT ISSUING F$
SIQna #,0 0 0 0.0 5
TOTAL FEE 10.08250
Plan check appilcanf
SINGLE FAMILYo 0 0 8 2 50 6
FIOME OWNER-54JILDER DECLARATION Narpe
11
I.hereby affirm that I arn.exempt frorn the Contractor's LfGense Address D 0[ ±8 6Law for the following reason (Section 7031.5, Business and
IProfeulons Code): City Tel. No
LJ I, as owner of the property, will do the work and the
structure Is not Intended or offered for sale (Saditon
70.01, Business and Professlons Code}.
CC>rN$ERUCTION LENDING AGENCY
1 fWeby affirm that there Isa construolon lending agency for '
the performance of the worst for which this pdrmrt Is Issued
(Sec, 3097, CI Y. C.)
te�dbr's Name,
Lenders Air dress
r certify that I have repd this appllcatlon and state that the
above Information Is correct. I agree to comply with all County
ordinances and State Iowa regulating Plumbing, and hereby
authorize repr tives of this Cgunty to enter upon the
abovo- properly f Inspection purposes.
SEE REyEItSE FOR EXPL,APLAtORY LANGUAGE
I g lata r Date