HomeMy Public PortalAbout9556 KENNERLY ST_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT JJJ��7
I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 I
insure, or a certificate of Workers' Compensation Insurance, 76A667A 'LJI
or a certified copy thereof (Sec. 3800, Lob. C. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
❑ Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant l WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER 15 G
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS ot
I certify that in the performance of the work for which this �y'�
permit is issued, I shall not employ any person in any manner SINK CITY l TEL. NO. L�b 711
so as to become subject to the Workers'Compensation Lows. DISHWASHER t
CONTRACTOR
Date Applicant CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL. NO.
Compensation provisions of the Labor.Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions'of Chapter 9 GAS SYSTEM OUTLETS D (/
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER Q
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
DATE _G —G 0.
License Number Lic. Class i�
FINAL
Contractor Date BY C
❑ I am exempt under Sec.
B.BP.C. for this reason
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
e
Plan check applicant ;
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name " " ''' a
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and rir _ _
Professions Code): City Tel. No. #(L
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section ta s „(
7044, Business and Professions Code). _
CONSTRUCTION LENDING AGENCY t
I hereby affirm that there is a construction lending agency for _:IF-,i-ANE
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Nome
Lender's Addressi"i `t'
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 inspection purposes.
•1. Z SEE REVERSE FOR EXPLANATORY LANGUAGE
IrZ2-CL
-91
gnature of Permittee Date