HomeMy Public PortalAbout10320 LA ROSA DR_Plumbing__ WORKERS' COMPENSATION DECLARATION 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)
r o cye{tified copy then f ffg55 j. 800, Lab, C,) COUNTY OF LOS ANGELES BUILDING AND SAFETY
P. y 0.O�� ���o/m-�aY W r.J7�1
Certified copy is hereby furnished.
FOR APPLICANT 70 FILL IN(PRINT OR TYPEI BUILDING 02
Certified copy is filed with the county building ' e - ADDRESS J
tion department. NUMBER FIXTURE OR ITEM e FEE LOCALITY
Date� AppliFant WATER CLOSET NEAREST G/
CERTIFICATE OF EXEMPTI ROM WORKERS' BATH TUB CROSS ST.
COMPENSATIO I URANCE SHOWER OWNER r
(This section need not be comp ed if the work involved by
the permit is for one hundred dollars ($100) or less.) LAVATORY MALL ADDRESS
A
I certify that in the performance of the work for which this or= QAQR
permit is issued, I shall not employ any person in any manner IllSINK CITYTEL. NO.
so as to become subject to the Workers'Compensation Lows. DISHWASHER
0a �AA^� CONTRACTOR O
Dale Applicant CLOTHESWASHER {N ADDRESS t
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR GO
Exemption, you should become subject to the Workers'
CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE y'� LIC.
deemed revoked. WATER HEATERO:l LICENSE NO, 0(/ CLASS G
LICENSED CONTRACTORS DECLARATION oo DISTRICT NO. P ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER 7ooe
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and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL 7 VALIDATION O
License Number Lit. Class C3 DATE Z—Z�'r�•3; U
FINALr ! O
Contractor Date rte- BY v E—v-a—V u
❑ W
I a tempt under Sec. H
B.BP.C. for this reason z
Plan check fee 00
Date:
Signature PLUMBING PERMIT ISSUING FEE$
S
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Nome
I hereby affirm that l am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and [8 O.7 Q
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the ,i u*.,. o a 5
structure is not intended or offered for sale (Section ,
7044, Business and Professions Code), o o 7& L F
CONSTRUCTION LENDING AGENCY e%2 S'5
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Nome
Lender's Address
I certify that I have read this application and state that the Polls
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 -me 'oned prop for spection purposes.
_ SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig(lure of Permi ee Dote