HomeMy Public PortalAbout6243 GOLDEN WEST AVE_Plumbing__ WORKER'S COMPENSATION DECLARATION 6DPW 9I89
76A667A APPLICATION FOR PLUMBING PERMIT
' 76A66 '
I hereby a`.4irm that !,,have a certificate of consent to self insure,
or a certificate of'Worker's Compensation Insurance, or a certified
copy thereof(Sec. 3800 Lab. C ,/
� � ,�} h COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
( 3VA
Policy No. - _ �ompany ,
Certified copy is hereby furnished.
/ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
t� Certified copy is filed with the county building inspection ADDRESS ! Z
depart ent. �, r/ NUMBER FIXTUWATER CLOSET
OR ITEM @ FEE LOCALITY
Date Applican �r� DO 6 NEAREST
CERTIFICATE OF EXEMPTION FROM•WORKERS' BATH TUB CROSS ST.
!' j.�� q
COMPENSATION INSURANCE ASSESSOR MAP BOOK PAGEL� PARCEL
,�� Off/
(This section need not be completed if the work involved by the SHOWER j
permit is for one hundred dollars($100)or less.) �� OWNER —
I certify that in the performance of the work for which this permit LAVATORY
MAIL
is issued, I shall not employ any person in any manner so as to SINK ADDRESS'
become subject to the Workers' Compensation Laws. !0 �
DISWASHER ��' CITY 7 o y e T .NO.
Date Applicant CLOTHES WASHER CONTRACTO l tt��
NOTICE TO APPLICANT: If, after making this Certificate of J /re 7
Exemption,you should become subject to the Workers'CompensationSWIMMING POOL RECEPTOR � �
provisions of the Labor Code, you must forthwith comply with such' ADDRESS
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
s
LICENSED CONTRACTORS DECLARATION CITY a^ TEL.NO. 0-
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER �t
(commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS / �G� LICENSE NO. a�/STATE LASS�J/tt3 f O
Professions Code, and my license is in full force and effect. "i DISTRICT NO. PROCESSED BY Q
J/ ? OUTLETS OVER
License Number 7Q-1 ✓/� Lic.Class •�/GO f�.+� 5 PE SYSTEM p O
//7�, /] 11�,e, / ��J1 [//y FINAL Q ��At_IL1wTION Ij,f
,{ j� ! r`� IL`s / /Date `/ % - DATE ,(— I l rl*`%, .,wrte a.
fly
Conttacto
❑ I am exempt under Sec.
FINAL
Y AL 33507272.10
B.&P.C.for this reason 1 ITEMS
Date: Plan check fee , TOTAL' 272 - 10
Signature
PLUMBING PERMIT ISSUING FEE$ CHECKS' 272.10
❑ TOTAL FEE .1313
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name •—
I hereby affirm that I am exempt from the Contractor's License Lawt!) �
for the City Tel. No. lifollowing reason (Section 7031.5, Business and Professions, Address + OJ f Al��17
ElCode: t 1 '
I,as owner of the property,will do the work and the structure
is not intended or offered for sale(Section 7044, Business
and Professions Code). ,
CONSTRUCTION LENDING AGENCY
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 ,
inform s'c ect. I agree to comply with all County ordinances
=State la s regulating PI bing, and hereby authorize
representatives of this County enter upon the above-mentioned
D
for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
y�ure of P rmittee D e