HomeMy Public PortalAbout6309 GOLDEN WEST AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION 74AWA
I herAby aZIrrp that I have . mate of consent to self CK .17 (_-.o APPLICATION FOR PLUMBING PERMIT
Insure, of ir cs. Acate of Workers'Compensation'Insurance,or r
a certified{d CA f(Sec.3800,Lab.C.) T,
���� COUNTY OF LOS ANGELES 13UILDING AND SAFETY
Policy No. Company
Certified popy is hereby furnlahled. FOR APPLICANT TO FILL IN (PPANT OR TYPE) BUILDING /- p
ApDAE88 GOL.ifWa W� �W .
f7a' ��spy is Mad% N.0 B 6R FIXTURE OR LTBM • FEE
Lk 6 �T`i�+ LOCALITY 71 r Cr I-T
Dato-1, Applicant WATER CLOSET NEAREST
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION) ROW7:—
S'
COMPEN$ATION INSURANSHOWER OWNER `( TA 4
(Ilii+ section need not be lett If the t tnvotved LAVATORY ADD
by the perTh it fot one by do and dohm (3100)'or las) BFNK
CITYh�� GL TEL. NO.Z -(
I certify that in the performance of the work for which this bi8HWA8H( Rtr
permit L hued, I shall not employ any person in any manner � CONTRACTOR ��llJ$ptfal QUI LGhd �IyC O
so al to become subject to the Workers' Compensation Laves. CLOTHES WASHER PVLwTZ ADDRESS
Date_Applicant SWIMMIN6 POOL RECEPTCIR W
NOTICE TO APPLICANT:If,after mating thb'Cnttiflcate of CITY TEL. NO
Exemptlop, you should become subject to the Workers' LAWN 8PFFINICLEB SYSTEM STATE �, - LIC. r —
Compensation provjaioni of the Labor CodLICENB NO. LASS
Co-de, you moat forth- �—1
with comply with such provW6n4 or this permit shall be WATER HEATER
dedmed revoked. OAS 8Y13TEM OUTLETS 1 DISTRICT NO. P C(88ED-B
LICENSEDCONTRACTORS D)9CLAdtArn0 N OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 8 PER8YSTEM
9 (commencin'it+ith Section 7006) of Division 3 of the Buai- r WrlC-exT GAIP FINAL yAI,IMTION
has and Professlom Code, and my llFense is In full fo}ce and DATE
affect. 1, tSiL
hseNumber'PI W1 Lie.Class I FINAL
Lice
pp�� l3Y
Oo-nZOU. ,pF�Zte
res lla 1 + �
I am exempt fio� the licensing reQglrements as I am a Plan check fee
Hceased as'cidtect or a raWrtered professional engineer PLU-MBING PERMIT ISSUING FEE$ /�f
acting in my profeesfonah capacity (Section 7051, Bus- y
Ineu and Profeasionf Code). TOTAL FIS
Lie.or Reii.No. Dale Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I ■m exempt from the Contractor's Addraw t- 71
p
License Lave for the following reason (9botion,703}.�S Buss C#y T.I.No.
ta and Professions Code): #,00 - 5
I, as owner of tbp property, am exclusively contracting 2 - 2200
with licensed contractors to construct the project
(Section 7044, BRsfness and Professions Code.).'
/ 0 °'022006
-CONSTRUCTION LENDING AGENCY
I hereby affirm that there L r construction leLding agency ` Z T}9—8 0
for the perfdtmancq of the Work for which this permit is
Issued(Sec. 3097,Civ. 1 1 ,` ` /� flt/
Lender's Name
Lender's Address_ Brv4'/(�A --Z'G7
I certify that I have read this application and statd that the ( \
above]nformptiop is correct.I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE v
ordinances and State laws-regulating Plumbing, and hereby
authorise represebtattves of this County to anter upon the
ture of Perm] 00 Date