HomeMy Public PortalAbout9189 JAYLEE DR_Plumbing_5/7/1991_fixtures Wb.RKER'S COMPENSATION DECLARATION 20-0026 DPW 9/89 �n p �a� pp
1 hereby affirm that I have a certificate of consent to self insure, 76A667A APPL�Il�6'-'�1TPON FOR PLUM p NG p°[ RNT
or a certificz;,e of yNorFer'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 T.O FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant G WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'` BATH TUB CROSS ST. t
COMPENSATION INSURANCE r{ ASSESSOR Q�
i(This section need not be completed if the work involved by the SHOWER MAP BOOK lJ PAGE6)` PARCEIO/Z
permit is for one hundred dollars($100)or less.) I OWNER
I certify that in the performance of the work for which this permit [ LAVATORY71 !r
is issued, I shall not employ any person in any manner so as toSINK' MAIL
become subject to the Workers'Compensation Laws. ADDRESS
DISWASHER CITY TEL.NO.
Date Applicant / CLOTHES WASHER
NOTICE,TO APPLICANT: If, after making this Certificate of CONTRACTOR f
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with,such ADDRESS
provisions or this permitshall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION f CITY TEL.NO.
I hereby affirm that I am licensed under provisions of Chapter 9WATER HEATER (L(commencing with Section 7000) of Division 3 of the Business and' STATE LIC. O
Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS r267P LICENSE NO. CLASS V
OUTLETS OVER DISTRICT NO. j PROCESSED BY
5 PER SYSTEM ll� X� �s' � . 0
License Number Lic.Class
FINAL
DATE '1,Z VALIDATION �
r
Contractor Date CL
❑ I am exempt under Sec. FFIINAL Z
BAP.C.for this reason
Plan check fee
Date:
Signature _,
PLUMBING PERMIT ISSUING FEE$ �?
❑ TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law _
for the following reason (Section 7031.5, Business and Professions Address _i € 651. _I
Code): _
City Tel.No. 2 i I GI{`
I,as owner of the property,will do the work and thestructure
AL
t
is not intended or offered for sale (Section 7044,-Business ,�t�,yy 6�';i ® =ems
and Professions Code). .0 ;r +fv VIj 3
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency for the C A GE }`)
L 3 C
performance of the work for which this permit is issued (Sec. 3097,
Civ.C.) l
Lender's Name
.-_F.Yt i Hil 7'CLIJ
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 ente upon the above-mentioned
pro ,Ji-nlspectio �rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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