HomeMy Public PortalAbout8903 HERMOSA DR_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consent to self in- 70-0026 DPW4%W
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surer or a certificate of Workers'Compensation Insurance,or p 6A667A
certified copy thereof (Sec. aLab. C. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS'
Policy No.-Company
any
❑ Certified copy is hereby furnished. BUILDING
ElFOR APPLICANT TO FILL IN(PRINT OR TYPE) �� yl
Certified copy is filed with the county building inspection ADDRESS L/
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY GLLA /C
Dtlte Applicant
WATER CLOSET(TOILET)
NEAREST C-/V
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNE�O
(This section need not be completed If the work Involved by MAIL ppyy�� ny1
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS 660
I certify that in the performance of the work for which this per- SINK CITY/ TEL. NO. - G
mit is issued, I shall not employ any person in any manner so
as to bec esu lect to the Workers' om ensoti Laws. DISHWASHER CONTRACTOR
Date Applicao CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY TEL. NO.
cation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. tCLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
GAS SYSTEM Z OUTLETS 0 ` .'t.y' a
I hereby affirm that I am licensed under provisions of Chapter O
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL 1
ViTCIDATION
fect. HOSE BIB DATE -Z -�I I a
License Number Lic. Class
FINAL O
Contractor Date BY TO A( '€ 19 m cc
6
rHtlai 11'x,lii0
I am exempt under Sec. f
- O f_HAMt-1t 'firs W
B.BP.C. for this reason
Plan check fee
Date: h
PLUMBING PERMIT ISSUING FEE§ _
Signature y� fl�iiij-{11]1}t �„'' ,!"+
SINGLE FAMILY TOTAL FEE d ,y_;6 3 1 AM 9;1r.
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name
Low for the following reason (Section 7031.5, Business and
Professions Code): Address
IYI I, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044,
Business and Professions Cade). Poo.CONSTRUCTION LENDING AGENCY
I hereby affirm that there is o construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3197, 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 uppn the
a htionedIt,perty ori I /. /urposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee � Dche