HomeMy Public PortalAbout8919 HERMOSA DR_Plumbing__ WORKER'S t-htIaveaceSATIONDECLARATION 76A667ADPyJ9rB9 APPLICATION FOR PLUMBING PERMIT
I hereby affirm tfi at J have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified ,
copy thereof(Sec. 3800 Lab.C.) '
Policy No. Company COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
❑ Certified copy is hereby furnished. BUILDING G
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) gDDRESS
Certified copy is filed with the county building inspection
department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date Applicant 2 WATER CLOSET G
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
BATH TUB
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the1
SHOWER MAPBOOK J.J 0 T PAGE Q�7 PARCELO
permit is for one hundred dollars 13100)or less.) OWNER i
I certify that in the performance of the work for which this permit 3 LAVATORY
is issued, I shall net employ any person in any manner so as to ' SINK MAIL ADDRESS
became subject to the Workers' Compensation Laws.
DISWASHER CITY _(i3 TEL.N . 2g 1-a
Date Applicant CLOTHES WASHER CONTRACTOR IWMVI Y JJ V
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption,you should become subject to the Workers' Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS
provisions or this permit shall be deemed revoked, 2, LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO. }
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER d
(commencing with Section 7000) of Division 3 of the Business and STATE LIC.GAS SYSTEM 3 OUTLETS LICENSE NO. CLASS V
Professions Code,and my license is in full force and effect. _
OUTLETS OVER DISTRICT NO ^ PROCESSED BY O
5 PER SYSTEM DISTRICT
Oy
License Number Lic.Class I.-
FINAL
a U
DATE 91` VAEIDA71ON W
ContractorDate 1 •:�i�' _���.ic,a
❑ I am exempt under Sec. FINAL // ,I .1—�9.=, Z
K En 8.8P.C.for this reason - rr t 3
' Plan check fee 3 ► J�JIi':L '-`-`
Date:
Signature PLUMBING PERMIT ISSUING FEES
❑ TOTAL FEE Ifl_
r
SINGLE FAMILY Plan check applicant nc
HOMEOWNER-BUILDER DECLARATION Name - - �I?Mil—Il�4i ..fR
I hereby affirm that I am exempt from the Contractor's license Law ^�`C1 _ �,
for the following reason (Section 7031.5. Business and Professions Address -
Co e):
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 Slate laws regulating Plumbing, and hereby authorize - - -
representatives of this County to enter upon the above-mentioned
property for inspection Eurposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
3-ao- �s
Si nature of Permitted Date