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Home My Public Portal About11002 GREEN TREE LN_Plumbing__ #� WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT f hereby affirm tha`I have a certificate of.consent to self 76A667A insure, or 3 certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof (Sec. 3800 Idb. C. COUNTY OF LOS ANGELES /y BUILDING AND SAFETY�� Polic 0 /� Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county buildi inspec- ADDRESS e tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Datecg �- A lica �� WATER CLOSET NEAREST Pp CERTIFICATE OF EXEMPTION FR WORKERS' BATH TUB c lj� CROSS ST. COMPENSATION INSUR NCE SHOWER OWNER (This section need not be completed if the work involved by _/' MAIL the permit is for one hundred dollars (:100)or less.) LAVATORY D ADDRESS I certify that in the performance of the work for which this / permit is issued, I shall not employ any person in any manner / SINK CITY TEL. NO. g_;,�j so as to become subject to the Workers'Compensation Laws. CONTRACTOR % DISHWASHER d0 _� l Date Applicant CLOTHES WASHER , !�r'Q ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR _ Exemption, you should become subject to the Workers' CITY , TL TEL. NO // Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM ! �� 5� with comply with such provisions or this permit shall be STATE _ n LIC. ezl deemed revoked. WATER HEATER LICENSE NO. J� CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS � �� {� � (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER a^ and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALI ATION O 0 7 �3 DATE � License Numbe - �. . _ @➢ Lic. Class � 0 / c FINXL Contractor, L A/re Dat / BY I am exempt under Sec. � B.&P.C. for this reason ► Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature 2 2 1 6.9 A TOTAL FEE Plan check applicant �� " # 0 0 0 0 0 5 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name - 10200 I hereby affirm that I am exempt from the Contractor's License Address o Low for the following reason (Section 7031.5, Business and - 102006 Professions Code): City Tel. No. c 73 0-8 5 ❑ 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 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 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 above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a :certificate of consent to self 76A667A insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF.LOS ANGELES BUILDING ANDSAFETY PolPolicy No. Company &�y�2- �7kEE Certified copy is hereby furnished. V F1 Certified APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed wit the co my buil g inspec- ADDRESS tion department. NUMBER FIXTURE OR ITEM @ FEE _�. 1d_ LOCALITY WATER CLOSET Date Applicant NEAREST CERT KATE OF EXEMPrl FROM ORKER BATH TUB CROSS ST. COMPENSATIOURA CE OWNER �U,Z�/(J •gd�L /L�� (This section need not be comd if thework involved by SHOWER the permit is for one hundred dollars($100)or less.) LAVATORY MAIL I certify that in the performance of the work for which this ADDRESS permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO. so as to become subject to the Workers'Compensation Laws. DISHWASHER c CONTRACTOR G+ •��j f�/�v s Sym Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: 'If, after making this Certificate of ADDRESS Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- / CITY l�/�J/ X/f��E� G�f TEL. N0.9�paf�3L 1 t/ with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATE � �Q J?� LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS / LICENSED CONTRACTORS DECLARATION DISTRICT NO. P CESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER ` /�(f and Professions Code, and my license is in full force and effect. 5 PER SYSTEM @. FINAL VAL ATION DATE License Number Lic. Class FIN Contractor Date B ❑ I am exempt under Sec. B.BP.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature • TOTAL FEE SINGLE FAMILY Plan check applicant ' HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. ❑ 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 RJ 7J 2..6'A; I hereby affirm that there is a construction lending agency for # o,o o o o 5 the performance of the work for which this permit is issued ( -o o 1 6 5 0 (Sec. 3097, Civ. C.). o 0 0 1 6500" Lender's Name 0,29-85 Lender's Address I certify that I have read this application and state that the S above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby au or' represe atives of this County to enter upon the ab ve- entione ropertXfor inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sign ture of . rmitte D