HomeMy Public PortalAbout9027 JAYLEE DR_Plumbing_7/7/1993_water fixtures and gas system I
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WORKER'S COMPENSATION DECLARATION 7DPW
W9/89
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I hereby affirm that I have a certificate of consent to self insure, -'
cr a,certifica a of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab. C.) \
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC.WORKS DIV.
Policy No. Company
❑ Certified copy is,hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Q ^ �Y6F
r/ ,p
❑ Certified copy is filed with the county building inspection ADDRESS -IQ o� —7 / VL
department. NUMBER FIXTURE OR ITEM Q FEE f'7/V 'r„ _.f � 4 f
LOCALITY 'L�
Date _ Applicant ' WATER CLOSET NEAREST -
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB
CROSS ST.
r' I -
COMPENSATION INSURANCE ASSESSOR
his section need not be completed if the work involved by the
SHOWER - MAP BOOK PAGE PARCEL
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permit is for one hundred dollars($100)or less.) OWNER
I certify that in the performance of the work for which this,•permit LAVATORY -/C,
is issued, I shall not employ any person in any manner so as toSINK MAIL
become subject to the Workers' Compensation Laws. ADDRESS L"t7"� Q�r]JY�G/fiAC
t ` ?
DISWASHER CITYC'S
TEL
.NO. .,•
Date Applicant / CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR
Exemption,you should become subject to the Workers'-Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS /10
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM _
LICENSED CONTRACTORS DECLARATION CITY1, TEL.NO. �-
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER
commencin with Section 7000 of Division 3 of the Business and STATE LI� O
( g ) "' LICENSE NO. CLASS--
0
LASS "- V
Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS
OUTLETS OVER
- DISTRICT P - SS Y
5 PER,SYSTEM 11,7-.Ij I o
License Number Lic.Class
FINAL - .) s- .s°y,= V
DATE VAL 4T6' p LLI
Contractor Date ?CIT AL 119 1 0 N
F1 FINAL i r'." a-Z
I am exempt under Sec.. By
B.&P.C.for this reason
Date:
Plan check feel''`
h � ,
PLUMBING PERMIT ISSUING FEE$ / V
Signature, nr .—
/ ?:!_II lel ill f '•
TOTAL FEE _ `r
❑
J1617-3 7 A
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name i
I hereby affirm that I am exempt from the Contractor's License Law
for'the following reason (Section 7031.5, Business and Professions Address
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 _
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.) l
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 inspe�purs,�,� .SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date -_ 1 3