HomeMy Public PortalAbout10140 LA ROSA DR_Plumbing__ WORKERS'COMPENSATION DECLARATION 7GA667A
I hereby affirm that I have a' certificate of consent to self ceatr (a-ea) APPLICATION FOR PLUMBING PERMIT.
insure, or a certificate of Workers'Compensation Iusurane ,or
a certified copy thereof(Sec.3800, Lab C.)
COUNTY OF LOS ANGELES BUI IN AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ) {�J
NUMBER FIXTURE OR ITEM FEE ADDRESS /Q � V� !N(
�-J Certified copy is filed with the county bu' 'ng inspection
LOCALITY
de 21 e 00) WATER CLOSET
Date o Applicant NEAREST
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER '
MAIL
(This section need not be completed if .the work involved LAVATORY
by the permit is for one hundred dollars ($100) or less.)
SINK CITYTEL.NOy(,j'_y o
I certify that in the performance of the work for which this DISHWASHERU
permit is issued, I shall not employ any person in any manner CONTRACT
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER0
ADDRESS '� F
Date Applicant SWIMMING POOL RECEPTORU
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.N06 W-7e-v d
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. In
Compensation provisions of the Labor Code, you must forth- / WATER HEATER LICENSE NO. �� CLASS G Z
with comply with such provisions or this permit shall be _
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. PRO ESSED By
LICENSED CONTRACTORS DECLARATION OUTLETS OVER Ud
1 hereby affirm that I am licensed under provisions of Chapter 15 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL VALIDATION
ness and Professions Code, and my license is in full force and DATE 7
effect.
FINAL
License Number 19 /�.�L Lie.ClassV,3
,`�`-' )�(yr� BY
Contractorh Date 0 ,3d/0 Q
F1 1 am exe t from the licensing requirements as I am a Plan Check fee - 1 /
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ 7� Q 1
acting in my professional capacity (Section 7051, Bus- --77 �)
iness and Professions Code). TOTAL FEE O'
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 Clot
License Law for the following reason (Section 7031.5, Busi- City -
ness and Professions Code): ,t�q� ;96 0 9,6 A
I, as owner of the property, am exclusively contracting RNA P,gs.
ST t g✓ ��+ppprrr
with licensed contractors to construct the project �� �CTT�-(i14• • • • 5
(Section 7044, Business and Professions Code). ` �Tgjv(
• 1250
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency • e e 12506
for the performance of the work for which this permit is '
issued(Sec. 3097.Civ.C.). 0 91 0 8'—8 2
Lender's Name
Lender's Address
I certify that 1 have read this application and state that the
above information is correct.I agree to comply with all County SEE REVERSE 17OR EXPLANATORY LANGUAGE -
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned proper for inspection purposes.
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Signa re f ern ittee Dae