HomeMy Public PortalAbout11021 GREEN TREE LN_Plumbing__ ., WORKERS' COMPENSATION DECLARATION APPLICATION L MIN PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
insure;'or a certificate of Workers' Compe�ation Insurance, CE 617(REV. 10/81)
or a certifig copy themSec. 380op C.) COUNTY OF LOS ANGELES BU�LDG�,AND SAFETY
Policy N � �� Company d"'� j�' c�
❑ Certified copy is hereby furnished.
Otion
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
gDDRESSCertified copy is filed ;aoon�
ith the cou building inspec- �department. / NUMBER FIXTURE OR ITEM @ FEE LOCALIT /
Date f Appli �'I����� WATER CLOSET 9' NEAREST
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' .M
COMPENSATION INSURANCE SHOWER OWNE
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL ,5
ADDRE •-� !/G, ��
I certify That in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK M CITY
so as to become subject to the Workers Compensation Laws. / DISHWASHER
CONTRACTO
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this.Certificate of ADDRESS •v
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL. NO.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. R CESSED Y
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS Sa 6
4 /�y
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER (/®
and Professions Code, and my license is in full force d ect. 5 PER SYSTEM m
. � L,, FINAL �" r VALI TION
License Numbe 11 Lic. Class &0` / ` @P
Contractov� /� DaTej FIN
BY
I am exempt under Sec. �
ed3
B.&P.C. for this reason Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$
Signature 2` 21 60 A
TOTAL FEE �
Plan check applicant # o o o o o 5
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name 4 - 1 02.00
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address o - 102006
Professions Code): City Tel. No. S30-85
❑ 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). Pr
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
ab ve-mjntitn-5 perty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature -of-Permittee Date