HomeMy Public PortalAbout6139 KAUFFMAN AVE_Plumbing__ WORKERb'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
It I hereb4 offirnvli�at I have a certificate of consent to self in- 20-0026 DPW 4/90
sure,ori certificate of Workers'Compensation Insurance,or a 76A667A
certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC'WORKS
Policy No..127q&I-Company.
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) •s
Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
WATER CLOSET(TOILET) G
Date Applicant 2 NEAREST'
C RTIFICATE OF EXEMPTION M WORKERS' BATH TUB CROSS SL ,
COMPENSATION I RANCE SHOWER OWNER
(This section need not be completed if the work involved by I MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so l CITY TEL. NO. o, 7
as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR �'
llmer
Date Applicant CLOTHES WASHER
ADDRESS _VCt11A111a
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. t` WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION. DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS �D
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL C� '•_VALIDATION
fect. HOSE BIB DATE o-laT
License Number -/1Lic. Class�— A�•f=` =7 �
/' .��i��'K!- Dat
FINAL - �•� --,.c
j i� 0
Contractor
ITE
El I am exempt under Sec. �Q '7 _ E L
Lou
B.&P.C. for this reason
Plan check fee
Date: ► _ ' 5 =t'd �
PLUMBING PERMIT ISSUING FEE$ J! t. A1.1.fir E =I
Signature
TOTAL FEE �T b
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION, Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name 1 t000 0 01 0 1
Law for the following reason (Section 7031.5, Business and ^{79 j AIN 't=•3
Professions Code): Address y.
El I, as owner of the property, will do the work and the City Tel. No.
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 Jencling agency for
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
above-menti ned property,for , spection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
S�nre of Permittee Date e