HomeMy Public PortalAbout11014 GREEN TREE LN_Plumbing__ ' d ®
A 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' Comp nsation Insur nce, CE 817(REV. 10/81)
or a ce ified'copy thereof (Sec. 3800 C.
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy N0 Company
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING.
Certified copy is filed with the colding inspec- ADDRESS Q
tion department. unt iNUMBER FIXTURE OR ITEM @ f/FEE LOCALITY
Date aF(f
Applic � i WATER CLOSET !7 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERSBATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER
'
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL
ADDRES��
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY
i
so as to become subject to the Workers Compensation Laws. B DISHWASHER
��" CONTRALTO c1y.
a
Dote Applicant CLOTHES WASHER ^ ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM �t
with comply with such provisions or this permit shall be STATE p- LIC.
deemed revoked. / WATER HEATER LICENSE NO. O CLASS C=
LICENSED CONTRACTORS DECLARATION DIST NQ, OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �.S!
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and ffect. 5 PER SYSTEM
FINAL
Sd G� � DATE VALI ATION
License Numbe // y Lic. Class
y— FIN
Contracto}! �"��� Dam' BY
❑ A.
I am exempt under Sec. A.
BAP.C. for this reason g
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ T.
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address # of o o,o,o 5
Law for the following reason (Section 7031.5, Business and
Professions Code): I City Tel. No. 1 0,090,00
❑ I, as owner of the property, will do the work and the o 0 0 (� Q v
structure is not intended or offered for sale (Section
7044, Business and Professions Code). Poo (),630-85
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 Kermittee Date