HomeMy Public PortalAbout10325 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 o certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
or a,ce tifi�opphir�o4f .Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES �sBUILDING AND SAFETY
-Polity No. VV L.o`'mpony.
❑ Certified copy is hereby furnished. i7
® 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 C FEE LOCALITY
Date.SO^�l^g3 gppliganteRANCEO
t WATER CLOSET O NEAREST L
CERTIFICATE OF EXEMPTIORKERS' BATH TUB CROSS ST.
COMPENSATION OWNER
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL
ADDRESS u (>'Jb
I certify that in the performance of the work for which this
permit is issued, I sholl not employ any person in any manner SINK CITY L TEL. NO,
so as to become subject to the Workers Compensation Laws. DISHWASHER
01 CONTRACTOR
Date Applicant 1 CLOTHESWASHEIR OV ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- SPRINKLER SYSTEM J!/
CITY C.. TEL. NO.
LAWN
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. ' WATER HEATER LICENSE NO. 5 CLASS C
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PR ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS rte•O _
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER Q
A.
�J
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL r ) VALIDATION V
A
License Number 60 Lic. Class G 3�2 u4�
pp FINOC
Contractor 662kDate (0�y'D� BY AL 0
W
❑ I ameemptunder Sec. y
8.8P.C. for this reason Plan check fee 1101. Z
Date: PLUMBING PERMIT ISSUING FEE S -
Signature
TOTAL FEE
LAdd,ess
ck applicant
SINGLE FAMILY 2 7 9.3 {(
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License 4 o 0 o e e 5
Law for the following reason (Section 7031.5, Business and Professions Code): Tel. No. 2 a ° 7 8 2 5
❑ 1, as owner of the property, will do the work and the n 8 2 G x
structure is not intended or offered for sale (Section 011,7044, Business and Professions Code), 0`'6 1 5-83
CONSTRUCTION LENDING AGENCY
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 Name
Lender's Address
I certify that I have read this application and state shot the 00.above information is correct. 1 agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-me tinned prop or inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si Lure of Permittee Date