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HomeMy Public PortalAbout9834 HALLWOOD DR_Plumbing__ WORKFRS' COMPENSATION DECLARATION 6=�PITMCAMN FOR PLUUVUBNG PERM W •.I„ • •. r .,I';ti'6ref}y`8ffirm that I hayre a certificate of consent to self 76A667A o �inst,+re, ct a certificate of Workers' Com nsation Insurance, CE 817(REV. 10/81) or a certifigO of (Sec. 3800 C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy fV6.� �'J •'C6mpan © Certified copy is hereby furnis ed. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �® Certified copy is filed witAte unty building inspec- ADDRESS tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Dates Apptican WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM-WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE / SHOWER 40 OWNER (This section need not be completed if the work involved by / MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS OD I certify that in,the performance of the work for which this. p permit is issued, I shall not employ any person in any manner SINK CIT TEL so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTO .� Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT:. If, after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY TEL LAWN SPRINKLER SYSTEM with. comply with such provisions or this permit shall be STATE vP LIC. GJ�3 deemed revoked. WATER HEATER LICENSE NO. pQ O CLASS LICENSED CONTRACTORS DECLARATION DIST, ICT NO. PR ES57 I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business, OUTLETS OVER L (� and Professions Code,and my license is in full force and ffect. 5 PER SYSTEM FINAL BALI ATION C. DATE Z`/ CLI License mb Lic. Class / O FINAL U. Contract Dote G BY � ❑ I am exempt under Sec. U B.&P.C. for this reason W Plan check fee ,,11 D EL' Date: PLUMBING PERMIT ISSUING FEE$ G� U Z Signature TOTAL FEE Q z.8 5 0 9 A Plan check applicant # o,o o 0 o 5 SINGLE FAMILY pp 1 ,o ° 5250 HOME OWNER-BUILDER DECLARATION Name o o 0 5 2 5 p 5 I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and ( 2 O 3-8 7 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). r ' 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 D 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 a 've-mentio ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Dote