HomeMy Public PortalAbout9811 HOWLAND DR_Plumbing__ .. WORKERS'COMPENSATION DECLARATION APPLICATION_ FOR PLUMBING PERMIT fI
hereby a�jirm-that I have o certificate of consent to self 76A667q - ... _.. .._
in Sure, or a certificate of Workers' Compensation Insurance, CE BV(REV. 10/81) ILJI
or a certified copy thereof[( ec. 3800, Lab. C.)/� / COUNTY OF ANGELES - —_ BUILDING AND SAFETY
Policy NO(e33 3�1 ?pmpany -Lie EY fttf
lfL`pll. Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADNG Gs
❑ Certified copy is filed with the county buildingiOR
nspec- ADDRESS F�I
tion department. NUMBER FIXTURE OR ITEM Gi FEE ) 1
LOCALITY TelYI IQ �•1•
0 A licant WATER CLOSET
pp NEAREST , �I
CERTIFICATE OF EXEMPTI N FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER Si OWNER g r
I W L
(This section need not be completed If the work involved by
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS-�C'�J 1�!' yjI pN Yr
I certify that in the performance,of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY '^ le- CJ TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR V reri 1
I Date - Applicant CLOTHES WASHER ADDRESS J80-7 Shlile Ile.
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY •TEL, NO.
Compensation provisions of the Labor Code, you must forth- WP�''('� ��//n
with complywith such provisions or this LAWN SPRINKLER SYSTEM
p permit shall be STATE p LIC. /�
deemed revoked. WATER HEATER LICENSE NO. J p 7G L'A55 U
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
1 hereby affirm that I am licensed under provisions of Chapter 9 / GAS SYSTEM OUTLETS 11 OG
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect, 5 PER SYSTEM FINAL VALIDATION
p-s _ • r. a,
License Number .;7 d /�O Lic DATE
Class _ 0
r
//�� JJ p � FNALI
Contractor0cea M B,�dJeCfDate 1D"��( RL BY
❑ I am exempt under Sec. �7j ( 0
7PA U
B.BP.C. for this reason _
Plan check fee w
Date:
PLUMBING PERMIT ISSUING FEE$ Z
Signature -
TOTAL FEE ..
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that i am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address 1) !/l a Je
Professions Code): City We -v I N Tel. No,q33-
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section r ', # 5 8 Q•�
7044, Business and Professions Code). I o 0 2 8 5 O
CONSTRUCTION LENDING AGENCY
1 hereby nffirm that there is a construction lending,agency for o 0 0 'z a 5 074
the performance of the work for which this permit is issued
(Ser. 3097, Civ. C.). 11,05t86
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 alt County .
ordinances and Stome lows regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-menti ne. property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE to-Z 4-8G
Signature of Permittee Date