Loading...
HomeMy Public PortalAbout11025 GREEN TREE LN_Plumbing__ 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' Compensation insu ance, CE 817(REV. 10/81) or a certified copy thereof (Sec. 3800, C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY ^� Policy ��7_iompany �,� ❑ Certified copy is hereby furnished. / /—•� C� FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec- ADDRESS tion de ariment. NUMBER FIXTURE OR ITEM Q FEE �/ LOCALITY Date Appligan WATER CLOSET a NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB / CROSS ST. COMPENSATION INSURANCE SHOWER OWNER e z (This section need not be completed if the work involved by MAIL �i r� the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESSL+�/ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK GTYo/ so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR ys• Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY7,4 with comply with such provisions or this permit shall be STATELIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT No. P OC Ss 0 BY I hereby affirm that I am licensed under provisions of Chapter 9 ` GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER >_ and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VA DATION 0 �/ / _ i License Number / x6` Lic. Class 99 � ,� � FIN Contractor �ri` n�/,7e- Date BY [_ CA ❑ I� I am exempt under Sec. � B.&P.C. for this reason g Plan check fee Date: Signature PLUMBING PERMIT ISSUING FEE$ © 2 1 5 8 A TOTAL FEE # o 0 0 0 o cj Plan check applicant SINGLE FAMILY ) - 0 9600 HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's LicenseAddress o 0 0 9 600' Low 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 0,00-85 �3 _$5 El 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 ab �roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signat re of Permittee Date