HomeMy Public PortalAbout9156 JAYLEE DR_Plumbing_12/17/1991_fixtures WORKERS' COMPENSATION DECLARATION li= P 10 MCAMN F011 PLUM o IG PERNT
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
s or a certified copy thereof ( ec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS.
�Ct at
Policy No.n 7 k- : omPpany
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR'TYPE) ADDRESS 9fs� " fin; LZL DA
It copy is.filed with the county building;inspeo-
tion dep rtment. C'd)I' Ste' /CJ/JEus,—.. �, NUMBER PIXTUREORiTEM @ FEE LOCALITY
iApplicant �J€ '�/ WATER CLOSET 2 p
Date '� NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNEROw i6'
SHOWER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I-certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY IP0—i T TEL. NO. )
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR C )1 j.6S C4A,1ST-
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of S t/� Ari -
Exemption, you should .become-subject to the-Workers' SWIMMING POOL RECEPTOR
CITY TEL. NO.��•�2
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM �-?�.�Le%�Ava- v
with comply with such provisions or this permit shall be STATELIC. p
deemed revoked. WATER HEATER LICENSE NO. �- CLASS --
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby off irm"that I am licensed under provisions of Chapter 9 -GAS SYSTEM OUTLETS.
(commencing with Section 7000)of Division 3 of-the Business OUTLETS OVER
and Professions Code, and m license is in full force and effect. 5 PER SYSTEM
y
DATE
AL - ) VALIDATION
License Number�615 614 Lic. Class ��� O.
FINAL
Contractod®11ILAY GUIs-C< . Date 4 BY
ElI am exempt under Sec: �'
B.&P.C.,for this reason N�
Plan.check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOMEOWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's license• Address
Low for the following reason (Section 7031 5, Business and -
Professions Code): :.':ta, a,
City Tel. No. _._ ..._
❑ I; as owner of the property, will do the work•and the e
structure is not intended or offered for. sale-(Section w '
7044, Business and Professions Code). ° €i. A.
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 : . E
,(Sec. 3097, Civ. C.).
Lender's Name !}`[s's - '"s: - s
Lender's Address4.'ll_:
r T
i
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 6 on'the
above-mentioned*property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date