HomeMy Public PortalAbout9948 HOWLAND DR_Plumbing__ T :'WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT ��77
f he affirm that I have a certificate of consent to self 20-0026 DPW 6/87 C, 1,
insure, or 0.certificate of Workers' Compensation Insurance, 76A66,7A 1u�
ora certified copy
,thereof fSec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Policy CCllony
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING y
Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM @ FEE � �J
�1
Date Applicant LOCALITY T I
WATER CLOSET 4 7J NEAREST I
CERTIFICATE OF EXEMPTION R M WORKERS' BATH TUB - o CROSS ST.
COMPENSATION IN ANCE SHOWER t OWNER
(This section need not be completed If the work Involved by MAIL (� Y,9
�{ 6
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS d 9 �t� ",ii vI.
I certify that in the performance of the work for which this i
permit is issued, I shall not employ any person in any manner SINK ,Z 4 ID CITY. cA�. TEL. NO. ��'�
so as to become subject to the Workers'Compensation Laws. DISHWASHER �j
ii 4 �� CONTRACTOR A
Date Applicant CLOTHES WASHER 1"7 SS ADDRESS '
NOTICE TO APPLICANT: If, after making this Certificate of r)✓
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation rovisions of the Labor Code, you must forth- CITY C TEL. NO, �' ✓dam
P p Y LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE 7r�� LIC.
deemed revoked, WATER HEATER 4- � LICENSE NO. 9 trh7 CLASS G
LICENSED CONTRACTORS DECLARATION DISTRICT NO. OCESSED B
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETSI SS
i (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER �' U
and Professions Code,and my license is In full force and effect. S PER SYSTEM r FINAL VA TION 0.�
� �//,�,, (, '- DATE
License Number �� Lic. Class_ 2 5 b 'S ��
FINAL �j� 0.M
Contractor Date _ BY f`(�V
I am ee pt under Sec. u
B.BP.C. for this reason CL'
Plan check fee ® Cl)
Signature
Date: PLUMBING PERMIT ISSUING FEE$ 2A -75--
TOTAL FEE
Plan check applicant i1 . .
SINGLE FAMILY `
HOME OWNER-BUILDER DECLARATION Name T
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address
Professions Code): Tel. No.
City :,•;:3,: _-�
❑ ,l i�.:
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
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 State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
- -�-9�-
Signatu I
of Permittee Date