HomeMy Public PortalAbout11003 GREEN TREE LN_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
igsura,_or n certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) it
or a cer�yfled copy thereof (Sec. 3809, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy"No 4 5 7� Company
❑ Certified copy is hereby furnished. /ll
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING J
�C�/Certified copy is filed with the count building inspec- ADDRESS deqJ ,y! _ /J .
✓— tion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY (�G
WATER CLOSET /� 6p
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' a G BATH TUB a CROSS ST. '
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars ($100)or less.) LAVATORY �Q MAIL
_// 16/
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I certify that in the performance of the work for which this ADDRE
31.51
permit is issued, I shall not employ any person in any manner SINK dd CITY� TEL. NOY�
so as to become subject to the Workers Compensation Laws. j DISHWASHER f `C/� /
SFS CONTRACTOR
Date Applicant CLOTHES WASHER 194)NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS ®
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR _
Compensation provisions of the Labor Code, you must forth- CITY TEL. N
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall beSTATE 7� LIC. /17
deemed revoked. / WATER HEATER OO LICENSE NO. / CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. P OCESSED BY
GAS SYSTEM OUTLETS �)
I hereby affirm that I am licensed under provisions of Chapter 9 U (�
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER Z >�
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
/ DAT VALID ION V
License Number Lic. Class/ S� 99
�/J�/ /��,
IF NContractor//�,l>"�` Idzlyle DateEJ Y
LM
I am exempt under Sec. �
B.BP.C. for this reason2 1 t5,8 A
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$ �, ON # 0 0 0 0 0 5
Signature__
TOTAL FEE ° 1 0.200
Plan check applicant do SINGLE FAMILY pp o - 102005
HOME OWNER-BUILDER DECLARATION NameI3 Q 8 5
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
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
bovesnea' ed property for inspection purposes.
`/�%c� ��_ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date