HomeMy Public PortalAbout11024 GREEN TREE LN_Plumbing__ r 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' Com ensation Insurance, CE 817(REV. 10/81)
or a certified copy th��ee'reof (Sec. 3800 ab. C.) / COUNTY OF LOS ANGELES BUILDING AND SAFETY
P❑oliicy N �� /`� Company
Certified copy is hereby furnished. '
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING l/6
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM @ / FEE LOCALI /�,>�,,�.,
Date Applicari ' WATER CLOSET /o .._ NEAREST
` 1f2
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER
SHOWER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRE �L
I certify that in the performance of the work for which this r
permit is issued, I shall not employ any person in any manner SINK 16 CITY / -,)
so as to become subject to the Workers'Compensation Laws. DISHWASHER Kz9
Cf,
CONTRACTOR -26; A` �
Date Applicant CLOTHES WASHER ADDRESS �eL;h
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY
LAWN SPRINKLER SYSTEM r
with comply with such provisions or this permit shall be STATE ^� /
LIC. P 7
deemed revoked. WATER HEATER LICENSE NO. ,/(� V CLASS t� y�—
LICENSED CONTRACTORS DECLARATION J DISTRICT NO.. R ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 4y'�
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions CF// and my license is in fu11 /4E/e pti`d effect. S PER SYSTEM A.
FINAL VALI ATION 0
License Number Lic. Clas c„�� CM
�/11 8 L.
Contracto Date BU
❑ I am exempt under Sec.
B.&P.C. for this reason Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ z 2 1 a 9 A
Signature 1 o Q/„ 8:p=
TOTAL FEE 6 �`/CS G v
SINGLE FAMILY Plan check applicant Q53 0 8 5
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
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
above-manlinned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee Date