HomeMy Public PortalAbout11026 GREEN TREE LN_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
'-:1 herekg affirm that I have a certificate of consent to self 76A667A
insure, or'a certificate of Wdtkers' Co nsation Insuspnce, CE 817(REV. 10/81)
or a certd�,�the�eof (Sec. 380 C.) s COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polic o. Comp j�
❑ Certified copy is hereby furnished.
El
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the count g inspec- ADDRESS
tion department1�7 . NUMBER FIXTURE OR ITEM @ /FEE LOCALIT
Date Applica WATER CLOSET p NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNS
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars (;100)or less.) LAVATORY MAIL
ADDRESS., G`(/• v .
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 CITY :E ��'7 1
so as to become subject to the Workers Compensation Laws. DISHWASHER
CONTRACTOR ?�
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR � Y2..
Exemption, you should become subject to the Workers' CITY /
Compensation provisions of the Labor Code, you must forth- � �7 Y
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. l WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DIST V PR ES D 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 f
and Professions Code and my license is in full fort and effect. 5 PER SYSTEM FINAL
6 �,, DAT VALIDAT N
License Numbef� ��Lic. Clas ,/J `� � �Z99
f FIN O
Contractor Date' BY 0
I am exempt under Sec. �
B.&P.C. for this reason
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$ t 9 2 1 5,7A
Signature
11 1 TOTAL FEE
07D # 000005.
Plan check applicant
SINGLE FAMILY o 0 9 6 0 Q
HOME OWNER-BUILDER DECLARATION Name
1 hereby affirm that I am exempt from the Contractor's License Address o 0 . 96005
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. d3 0 e 8 5
❑ 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
avkhorize representatives of this County to enter upon the
bpi,e-mentaaeel-pcQperty for inspection purposes.
�J SEE REVERSE FOR EXPLANATORY LANGUAGE
ignp5ture of Permittee Date
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