HomeMy Public PortalAbout10300 LA ROSA DR_Plumbing__ WORKERS' CI have COMPENSATION cafeDECLARATION
corse APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
insure, or a certificate of Workers Compensation Insurance, CE 817(REV. 10/81)
/rr�rt'rfie—ORliii fit Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
'Y—O. /i l vi.. 4", GOT#/ /
P❑ollcy No. Company r.asiThJ l
Certified copy is hereby furnished.
FOR APPLICANT i0 FILL IN(PRINT OR TYPE) BUILDING 1030& J
Certified copy is filed with the county building inspec L
ADDRESS 1
40 ill
lion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITYi"I M G/
Date to-ly-- Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTIO OM WORKERS' BATH TUB QO CROSS ST. R
COMPENSATION I URANCE SHOWER O OWNER ij
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY C L TEL NO.�(9
so as to become subject to the Workers Compensation Laws. DISHWASHER J CA
CONTRACTOR
A
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS f G CC)
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY &5' GL rnowj TEL. NO. Ott'
LAWN SPRINKLER SYSTEM JCJ 'r `07
with comply with such provisions or this permit shall be STATELIC
deemed revoked. WATER HEATER O LICENSE NO. 5 OO CLASS
LICENSED CONTRACTORS DECLARATION DlSTRIC:_tIQ. OCESSED BY
I hereby affirm that I om licensed under provisions of Chapter 9 GAS SYSTEMto OUTLETS ID
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER 1 �,4
and Professions Code,bnd my Iicense is is full force and effect. 5 PER SYSTEM FINALa
ATE
p}f� D
VALIDATION O
License Number c/`� Lic Class G
DC
FINAL J O
Contractor Date� 8V U
W
El am mpt under Sec. w
B.BP. . for this reason Plan check fee 111111. 2
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and '`. 2 8 Q 9 A
Professions Code): City Tel. No.
; oeeea5
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section11011. ) o u 711 2 Jr ,
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY of ° 7 8 2 Jr v
I hereby affirm that there is o construction lending agency for
the performance of the work for which this permit is issued G 1 5,-83
(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
abov 'oned Prop ert pection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si lure of Permittee Date