HomeMy Public PortalAbout6245 GOLDEN WEST AVE_Plumbing__ WQFIKER'SCOMPENSATION DECLARATION 6DPW 9/89
76A667A APPLICATION FOR PLUMBING PERMIT
' 76A66
I hereby affirm that 4 have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insur nce, or a certified
copy thereof(Sec. 3800 Lab, g 4
/ / 9 COUNTY OF LOS ANGELESDEPT.OF PUBLIC WORKS DEPT. OF.PUBLIC WORKS DIV.
Policy No. Company
Certified copy is hereby furnished. BUILDING f r
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS (d �
Certified copy is filed with the county building inspection
de artm nt. ` NUMBER FIXTURE OR ITEM Q FEE
� , 1 LOCALITY
Date l I Applicant �l ! ,/'7dC �� WATER CLOSET J
NEAREST
CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB OASSESSOR
COMPENSATION INSURANCE
(This section need not be completed if the work involved by the SHOWER i MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) LAVATORY OWNER
I certify that in the performance of the work for which this permit r J/
is issued, I shall not employ any person in any manner so as toMAIL
SINK ADDRESS
become subject to the Workers'Compensation Laws.
DISWASHER CIT !4 y-7�,8 I TE .NO.
Date Applicant CLOTHES WASHER / �J / /�` l l
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTO
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Exemption,you should become subject to the Workers' Compensation SWIMMING POOL RECEPTOR ,,
provisions of the Labor Code, you must forthwith comply with such ADDRESS i a /L t
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM 333����7777 �{�- TEL
c
LICENSED CONTRACTORS DECLARATION CITY rv� TEL.NO �-
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER '�a ''"�� IL
ISTATE LIC.(commencing with Section 7000) of Division 3 of the Business and LICENSE NO. X1 CLASS '` 3�!
Professions Code, and my license is in full force and effect. > GAS SYSTEM OUTLETS (�
OUTLETS OVER DISTRICT NO. PROCESSED BY
r - 5 PER,;SYSTEM
�./�� +�
License Number JLic.Class ef
FINAL VALIDATION W
Contractor )-lM / i I/�-- Y ! Date r DATA /y f� 1 h, — C0
❑ I am exempt under Sec. gy��^_ !�✓�! �tr. i ITEMS
T fit 272.iG 3
B.&P.C.for this reason _ / 1 1 1 1 t
Plan check fee
Dater TOTAL 272. 10
PLUMBING PERMIT ISSUING FEE$ Lr 1�
Signature CHECK L%
❑ TOTAL FEE �� CH"E .0
Plan check applicant 4ririt'tl3G ar.P.i
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions Address
Code): � 1 Atlifl:it
❑ 1,as owner of the property, will do the work and the structure Lt1
City Tel. No. Gfv't
is not intended or offered for sale (Section 7044, Business
and Professions Code). ,
CONSTRUCTION LENDING AGENCY
I 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 certifyhave
,,I;2ad this application and state that the above '
inforrfiation is correct. I agree to com ly with all County ordinances
an tate laws regulating Plu ng, and hereby authorize
represen 'ves of this County tq en er upon the above-mentioned
ty for i pectioh purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permi ee Datef