HomeMy Public PortalAbout11020 GREEN TREE LN_Plumbing__ (
WORKERS' COMPENSATION DECLARATION
hereby affirm that Ihave.-a certificate of consent to self 76A667A APPLICATION FOR PLUMBING PERMIT
insure, or a certificate of Workers' Compensation Insuranc CE 817(REV. 10/81)
or a certif d copy thereof Sec. 3800, L ) COUNTY OF LOS ANGELES -BUILDING AND SAFETY
Policy°:�7 " Company �✓ " ���
❑ Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the count gilding inspec- ADDRESS
tioZd artent. NUMBER FIXTURE OR ITEM @ FEE LOCALI Y
Do Applica 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
the permit is for one hundred dollars ($100)or less.) 1/_/ LAVATORY i� ADDRESS
I certify that in the performance of the work for which this p�
permit is issued, I shall not employ any person in any manner SINK CITY
so as to become subject to the Workers Compensation Laws. DISHWASHER `✓
-� CONTRACTOR
Date Applicant CLOTHES WASHER ADDRES '
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STAT / LIC v��9
deemed revoked. WATER HEATER LICENSE NO.El CLASS c7
LICENSED CONTRACTORS DECLARATION DISTRICT NO. P CESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full forc�nd effect. 5 PER SYSTEM FINAL
G / �/C�
DATE//' VALI TION V
License Numb/ �U / Lic. Class
ol irii� � - "L,
Contract Date lCA
ElI am exempt under Sec. �
B.&P.C. for this reason
Plan.check fee
Date: PLUMBING PERMIT ISSUING FEE$ 67)7
Signature
TOTAL FEE 2 21 61 A
Plan check applicant # o o 0 o o 5
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name ( ° 1 0 2 0 0
1 hereby affirm that I am exempt from the Contractor's License Address ° ° 102 Q 0
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. 030-6'-85
❑ 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 pool
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
ab ve- n ion roperty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Permittee Date