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HomeMy Public PortalAbout5909 IVAR AVE_Plumbing__ WORKERS'COMPENSATION DECLARATIONp Pl�LSkICG=d75©H FOR U L��JUVULDJOHG PERNU :I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 _ insure, or a certificate of Workers' Compensation Insurance, 76A667A or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company Certified copy is hereby furnished. ❑ . FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING `n Certified copy is filed with the county building inspec- ADDRESS Ct tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY WATER CLOSET \ \� Date Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TU8 CROSS ST. COMPENSATION INSURANCE OWNER (This section need not be completed if the work involved by - SHOWER �b the permit is for one hundred dollars($100)or less.) LAVATORY MAIL ADDRESS MA3' Icertify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY: \ + �i� TEL. NO.• so as to become subject to the Workers Compensation Laws. DISHWASHERR t CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you .should become subject to the,Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL. NO. with comply with such provisions or this permit shall be 111 STATE LIC. deemed revoked. WATER HEATER / LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. dA PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �/D y (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER Q and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINALVALID�►TI®id CLIDATE 0 License Number Lic. Class J O U. FINAL r.-•- Contractor Date BY O ❑ I am exempt under Sec. Wi1 B.&P.C. for this reason Plan check fee Date; PLUMBING PERMIT ISSUING.FEE$ Signature TOTAL'FEE �� Plan check applicant _ SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I.hereby affirm that I am exempt from the Contractor's License Address $. Law for the following reason (Section 7031.5, Business and =3"" Professions Code): 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 r c'; I hereby affirm that there is a construction lending agency for (�s.�s�r.(;^� •,j3 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 bove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE gnatu of Permittee Date