HomeMy Public PortalAbout11010 GREEN TREE LN_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I Hove a certificate of consent to self 76A667A
insure, or a certificate of Workers' Comp sation Insura e, CE 817(REV. 10/81)
or a ce ified copy thereof (Sec. 38oQ C.) COUNTY OF LOS ANGELES BUILDING AND SAFE
Policl o� .�/�Company
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the cou building inspec- ADDRESS
T tion de rtment. NUMBER FIXTURE OR ITEM @ FEE
LOCALIT
Dated Applicant �vv WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNS � �
(This section need not be completed if the work involved by MAIL r
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS �✓,
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TE .
so as to become subject to the Workers Compensation Laws. 1 DISHWASHER
CONTRACTOR ryL
Date Applicant CLOTHES WASHER J
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or This permit shall be STATE LIC.
deemed"revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISjgICT, O OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force aannd�efffe_ct. 5 PER SYSTEM FINAL VALI ATION
DATE
License Numbed' Lic. Class
_` FINAL OF
@'
ContracIarl`mleeow� DoTe� / BY ® "
I am exempt under Sec.
B.&P.C. for this reason
Date:
Plan check fee ® P
PLUMBING PERMIT ISSUING FEE$
Signature � � # o 0 0 0 0 5
TOTAL FEE
� o 09600
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name o 0096007-
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address G!0 Q:8 5
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
abov - ntio erty for inspection purposes.
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SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of P ittee Date