HomeMy Public PortalAbout6059 GOLDEN WEST AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION 76A667A
I hereby affirm.that I have a certificate of consent to self CE 817 (2-80) APPLICATION F O R PLUMBING PERMIT j
insure, or a certificate of Workers'Compensation Insurance,or LJ
a certified copy thereof(Sec. 3800,Lab C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY-
Policy No. Company
El Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT'OR TYPE) BUILDING
ADDRESS p f F
Certified copy is filed'�vith the county building inspection NUMBER FIXTURE OR ITEM • FEE
departmentWATER CLOSET p� LOCALITY
Date t Applicant NEAREST
BATH TUB CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION'INSURANCE SHOWER OWNER y
3: Om MAIL ,
(This section need not be comleted if the work involved LAVATORY A'D D R
pESS
by, the permit is -for one hundred dollars ($100) or less.) _ 4
SINK f(ir�� CITY TEL NO',
I certify that in the performance of the work for which this DISHWASHER O '
permit is issued, I shall not'empI y ny person in any manner CONTRACTOR ..
so as to become subject to theW pensahon LawsADDRESS 501 0'
CLOTHES WASHER
DateApplican �� Ci`Zf✓��sr. SWIMMING POOL RECEPTOR ~
NOTICE TO APPLICANT„_L£,,f a ing this Certificate o CITY TEL NO.
-
Exemption, you should become sub ect to the Workers' LAWN SPRINKLER SYSTEM,
P J _ STATE LIC to
Compensation provisions of the Labor Code, you must forth- WATER HEATER LICENSE NO lJ CLASS z
with comply with such provisions or this permit shall be
deemed revoked GAS SYSTEM OUTLETS DISTRICT NO PROCESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 15 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi-.- FINAL
ness and Professions Code, and y license is in full force and - DATE VALIDATION
�Q
effect. /
�1 FINAL
License Number U� Lic Class.'✓ BY eV-1
Contractor Date
aI am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ 191
acting in my professional capacity (Section 7051, Bus- 191-10
acting
and Professions Code) TOTAL FEE
Lie.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that f am exempt from the Contractor's Address
License Law for the following reason (Section 7031 5, Busi- City Tel No
ness and Professions Code):
1, as owner of the property, am exclusively contracting a 1 29.8A-
with licensed contractors to construct the project
(Section 7044,Business and Professions Code). #,o'o .o o o 5
CONSTRUCTION LENDING AGENCY 2 0,o 2 5 0,0
I hereby affirm,that there, is a construction lending agency
for•the performance of the work for which this permit is a '_ o o o�2 S 0'0.5 '
issued(Sec. 3097,Civ.C).
Lender's Name
;0.9.2,2-8 1
'Lender's Address
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE "
ordinances and State laws regulating Plumbing, and hereby
autho a represen at ves of this County to enter upon the
ab e�nenticii y for ms ction purposes
L
Signature of Permittee Date y ,