HomeMy Public PortalAbout6120 GOLDEN WEST AVE_Plumbing__ WORKERS':COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I,here'b`affirm that I have a certificate of consent to self in- 20-0026 DPW 4/87
71Y .76A667A _
sure or a'certifi�ate of Workers'Compensation Insurance,or CE 817(REV. 8/86)
certifi@d copy thereof (Sec. 3800, Lab. C.
COUNTY OF LOS ANGELES DEPT. OF.PUBLIC WORKS
Policy,-Nb.. Company .... _.
F] Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
Certified copy is filed with the couniy building inspection ADDRESS o'-� kP'i ✓v
department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date Applicant •WATER.CLOSET(TOILET.) V NEAREST � A_
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. f''i� -11p
COMPENSATION INSURANCE SHOWER d OWNER
(This section need not be completed.if the work involved by /; MAIL
dd _
the permit is for'one hundred dollars ($100)or less.) LJLAVATORY 0 ADDRESS
I certify that in the performance of the work for which this per- 1 1. �9�
mit is issued, I shall not employ any person in any manner so SINK CITY TEL. 'Ti0 e,5
as to become subject to the Workers' mpen tion S. ^^ DISHWASHER
r( , CONTRACTOR
Date_ " Applicant CLOTHES WASHER r
ADDRESS
NOTICE TO APPLICANT: If,after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITYTEL. NO_1,01
sation provisions of the,Labor Code, you must forthwith comp- -._ LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE uC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. P SED BY
I hereby'affirm•that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of,the Business OUTLETS OVER O o
and Professions Code, and my License is in full force and of 5 PER SYSTEM FINAL VALIROTION
fect.
DATE' O
License Number Lic. Class U
FINAL
Contractor Date BY O
• .I am exempt under Sec. r
B.&P.C. for this reason Plan check fee ► �� g
Date: PLUMBING PERMIT ISSUING FEE $
Signature �
TOTAL FEE �` �� ;2993,,6 A
SINGLE FAMILY ' # 0 0 0 0 0 5
HOME OWNER-BUILDER DECLARATION Pian check-applicant ��
To,08250
hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and o'o• 0
82 5 0.Cx5'
ProfessionsCode): Addres's .
0 .
I, as owner of the property, will do the work and the city Tel. No. 6,2.0 8 8
structure is not intended or offered for sale(Section 7044,
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
1 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.).
Lender's Name
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
ordinances and State laws regulating Plumbing,-and hereby
authorize representatives of this County to enter upon the
abov. - enticyhed r�tyor ction purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee Date