HomeMy Public PortalAbout9168 JAYLEE DR_Plumbing_3/16/1982_swimming pool receptor WORKERS'COMPENSATION DECLARATION 76w667A
I hereby affirm that I have a certificate of consent to self CE 817 (z-eo) Q p PU C A T I®N FOR P L U M B U I�G P E RW T
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.)
<� �����j _ � COUNTY OF LOS AiVGELES / � � � BUfLDIiVG Ai\ID SAFETY
Policy No!5_9: 1ja com' 3 �a"
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS
�ertified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM O FEE
i i Par%.en1 IJL�7 Il LOCALIT�
Date 'Applicant^1oC CSDIs WATER CLOSET
NEAREST j —
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER
LAVATORY MAIL
(This section need not be completed if the work involved ADDRESS 5�,,w..�� CL
O
by the permit is for one hundred dollars ($100) or less.) SINK .
CITY TEL. NO. .
I certify that in the performance of the work for which this DISHWASHER
permit is issued, I shall not employ'any person in any manner CONTRACTOR)C, PO 014 0
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER
Date Applicant ADDRESS 3723 IU
SWIMMING POOL RECEPTOR { d
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO.63 „3d5
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM _
P J STATE 2�q �,,r LIC. 22
Compensation provisions of the Labor Code, you must forth- LICENSE NO. L t _Z CLASS C ._5_J
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. PR CESSEY
D B
LICENSED CONTRACTORS DECLARATION
OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM '
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL
' e__— _�z VALIDATION .
ness and Professions Code, and my license is in full force and DATE
effect.
-3 License Number Lic.Class FINAL
Contractor WA PtP�kS Date r J
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEES
acting in my professional capacity (Section 7051, Bus- h�y /3 -7
iness and Professions Code). TOTAL FEE 'V
Lic.or Reg.No: Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Address
License Law for the following reason (Section.7031.5, Busi- City Tel.No.
ness and Professions Code):
1, as owner of the property, am exclusively contracting z.3 2,9 6 A
with licensed contractors to construct the project
(Section 7044, Business and Professions Code). # 0.0 0,0 o'5
CONSTRUCTION LENDING AGENCY 2 0.o 1.250
I hereby affirm that there is a construction lending agency '
for the performance of the work for which this permit is o'o o 1 2.5 0 U
issued(Sec. 3097,Civ.CL,L1y��
Lender's Name lJ
. �03. 1 '6.-82
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above- entione pro rty for inspectio urpos
Si a ure of Pe ittee Date