HomeMy Public PortalAbout11007 GREEN TREE LN_Plumbing__ WORKERS'COMPENSATION DECLARATION,'y. CE 817( ) APPLICATION FOR PLUMBING PERMIT
r, -'affirm a that I have certificate of consent to self CE s�7 i-so
nsure, or a certificate of Workers'Co ensation Insurance,or
a,certi d i`opy tthereof.(Sec. 38 b. e.) ' COUNTY OF LOS ANGELES e^ BUILDING AND SAFETY
Policy No.`j"'' Compan `
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) 'BUILDING f7
Certified copy is filed wi cou uilding inspection NUMBER FIXTURE OR ITEM ® FEE
ADDRESS
i rtm t. - LOCALIT
Datew` Applica *�f WATER CLOSET NEAREST
elo
r BATH TUB ` CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER
MAIL
(This section need not be completed if the work involved LAVATORY ADDRESS
by the permit is for one hundred dollars ($100) or less.) }
SINK CITY TEL.
I certify that in the performance of the work for which this 0
DISHWASHER CONTRACTOR -f U
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER
Date Applicant ADDRESS 15� i'1
SWIMMING POOL RECEPTOR V
NOTICE TO APPLICANT: If, after making this Certificate of CITYl TEL. W
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. N
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be WATER HEATER. 0� LICENSE NQy� CLASS
deemed revoked. DISTRICT PFSO ESSED BY
GAS SYSTEMk OUTLETS (rf�
LICENSED CONTRACTORS DECLARATION OUTLETS OVER r
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL VALID ION
ness and Professions Code, and my license is in full force and DATE
effect.
License Numbe�� Lic.Class 4/' BY �� 9
B Y
Contract Date
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer Q
acting in my professional capacity (Section 7051, Bus- PLUMBING PERMIT ISSUING FEE$
iness and Professions Code). TOTAL FEE dv 21 6 6 A
Lic,or Reg,No. Date Plan check applicant # 0 0 0 0 0 5
HOME OWNER-BUILDER DECLARATION Name J 009600
Address
I hereby affirm that I am exempt from the Contractor's 0 009600x-
License
096,QOvLicense Law for the following reason (Section.7031.5, Busi- City Tel.No.
ness and Professions Code): 0,!!r,3 0_8 5
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project
(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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
abentierrei2'1Sr perty for inspection purposes.
-/
Si of Permittee Date