HomeMy Public PortalAbout8927 HERMOSA DR_Plumbing__ WORKERS]COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT
J herebpoffirm that I have a certificate of consent to self 76Ab 7A
insure, or a ce[f if icate of Workers Compensation Insurance, CE 817(REV. 10/81)
Sr a certified copy thereof (Sec. 3800, Lob. C) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Compony `
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS �
tion department. NUMBER FIXTURE OR ITEM @ FEE V,
LOCALITY r.- /JLE -/% h'.
Date Appligant WATER CLOSET ,m OC NEAREST /J
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB u'x is 00 CROSS ST. SAS:571 ' yQ
COMPENSATION INSURANCE 0 OWNER _
(This section need not be completed if the work involved by SHOWER 00
the permit is For one hundred dollars($100) or less.) LAVATORY • �o MAIL
/// ' fXJ ADDRESS �7 `� �,EL U/LLE
notify that in the performance of the work for which this
erm it is issued, I shall not emplo2z2L,
3 SINK D� CITY C-59N /�Q TEL NO.
so as to become subject to the WDISHWASHER U CONTRACTOR /J
r0 % `r
Date 'Z0 '� Applicant CLOTHESWASHER
NOTICE TO APPLICANT: If, after mating this Certificate of - ADDRESS �/S4 SEG//LLE
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY TEL NO /
Compensation provisions of the Labor Code, you must forth- z(.) /ylF/.�'X't�a ��- YS/
with comply with such provisions or this permit shall be �" LAWN SPRINKLER SYSTEM STATE LIC.
deemed revoked. WATER HEATER ,f o LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION U DISTRICT nlc�/ P C SED By
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM 9 OUTLETS Po � 00 VG` N
(commencing with Section 701 of Division 3 of the Business OUTLETS OVER }
and Professions Code,and my.license is in full force and effect. 5 PER SYSTEM FINAL /C VALID ION a
DATE O
License Number Lic. Class / tJ
FINA 01
Contractor Date BY O
r' U
W
I am exempt under Sec d
B.BP.C. for this reason W
Plan check fee plop
Date:
PLUMBING PERMIT ISSUING FEE$
Signature )
TOTAL FEE �(qSv t
Plan check applicant - ,e672E,,4,rJ✓
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name Adi/LJ/ST6E�
I hereby affirm that I am exempt from the Contractor's License
Lowf e following reason (Section 7031.5, Business and Address 3 -/ per, 3 5 1.5 A
Pro ssio s Code): City m /,J p Tel. No /��
gonanes
as owner of the property, will do the work and the
structure is not intended or offered for sale (Section 11110,7044, Business and Professions Code). 1 0 1 90.50
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for e o 19050'.
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.). ( 1.20-85
Lender's Nome )i F`1—,_Q U0 S 11
Lender's Address ,UAx-r'19 /YICAM1A, eA
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
&1ho, representatives of this County to enter upon the
ee e ro rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o ermit ee Dale