HomeMy Public PortalAbout10766 GRAND AVE_Plumbing__ WORKERS'COMPE�?SATIFJN,DECLARATJON20� APPLICATION FOR PLUMBING PERMIT
lura,
crfFI m that I hdve a ca� dte o€consent to self In. 7 4/87
I or certificate of Workers'ComperA Lars Insurance,or a CE 817(REV.9/86)
cerrifled cop,thereof (Sec. 0800, Lab. C.) fl
COUNtY OF LOS ANGELES DEPT. OF PUBLIC WORKS
pollcy.No: Comipany 'Siam �N
Certtfled copy Is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Q
I`C7� Certlfled copy Isflled with the bounty building Inspeo[on ADDRESS
L� department. NUMBER FIXTURE OR ITEM e FEE LOCAUTY
WATER CLOSET(TOILET)
Dpte� Applicant NEAREST
CERTIFICATE OF 10(11MbTION FROM WORKER$' .2 BATH TUB CROS5 ST.
COMPENSATION INSURANCE Z SHOWER D OWNER
(This section rid not be completed tf the work Inrgfwd bi
MAIL
the permft is for one hundred dollars(>{100)•or leu.) LAVATORY ADDRESS
f certify'that In the pprformdnce of the wook for which This per- A
mit Is Issued, I iholl not employ any person fn any manner so SINK
as to become subject to the Worken'CompBnsarlon I,ows. DLrHWASFJE
CONTRACTOR
Date Applicant CLOTHES WASHER
NOTICE TO'APPLICANT: If, after mpktng't-hIs-Co NflCate of Ex- ADDRESS
emptlon,you should become sub act to,the Workers'Compen- SWWAdNG POOL,RECEPTOR
{ CffY TEL 1J0.
sailors provlslohs of the Labor Code, you must forthwlih comp- OWN SPRINKLER SYSTEM
ly with such provrslorls or this permit shalt be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATIQN D157RICTNy6 \Z�$A
BY
t hereby afflrr�,that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS JC
9(commenring.wlth Sectlon 7000)of Division 3 of the Buslnon OUTLETS
fec' Professlon}-Code, and my license Is In full force pact of- 5 PER FINADATEL4,0 �'�� VALI ATION a
ticense tfumber LIc. Class �' O
U
' FINAL � S
Contractor Date BY O
❑ I am exempt under Sec. U
W
B:BP.C. fqr this reason, Plan check fee
{?ate: PLUMBING PERMIT ISSUING FEE S
`Signature � _
TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant 5
I hereby affirm that I am exempt from fhe Contractor's License, NameALL C�.i
Law for the following r"on (Section 7031.5; Buslrjau and q
Professloni Code): Address �� 7 ' 33 00.
1,as owner of the property, will do the work and the Clty Tel. No. 111
structure Is not Intended or offered.for sole(Sedlon X044,
B4slriess and Professions Code).
TA. 1.3300
POO
CONSTRUCTION,LENDING AGENCY 4.fC s 133■QFI
I hereby affirm that there is a constructlon,lending ogenty for
y� �yy
the perforrrtan4e of the work for which tHIs permit Is Issued ■
(Sec 3097,tiv. C.). 1
Lerlder's.Noma_ 000Q00101 1/ 9/90
Lender's Address 8152 1 AM10:20
I certify that I have read this appllcafld❑ and state that the
above Information Is correct. I agree to comply with all County
ardingnces and State lawregulatrn9 PLumIpin9, and hereby
authorize representatives o thls Coonty to enter upon the
mentioned prope r I Ion purposes.
6 .�; SEE REVERSE FOR EXPLANATORY LANGUAGE
Slg tore of Permittee Dgte
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