HomeMy Public PortalAbout10330 LA ROSA DR_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I hove a certificate of consent to self 76A667A
insure, or a certificate of Workers' Compensalion Insurance, CE 817 (REV. 10/81)
or a certified copy thereof Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Q°r�i2oy-oW-a Cor97y WA1,ASAa— Go'F*/ /0336
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county buildin ins ec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM ® FEE
LOCALITY .�
Data _gppl stool WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTI N ROM WORKERS' BATH TUB CROSS ST.
COMPENSATION URANCE OWNERMJ/Z MW L
(This section need not be completed if the work Involved by SHOWER MAIL A—
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK 00 CITV r TEL. NO.
so as to become subject to the Workers Compensation Laws, DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ir/ ")CO
NOTICE TO APPLICANT: If, after making this Certificate of O ADDRESS `'
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY Cs� TEL. NO.
LAWN SPRINKLER SYSTEM �J
with comply with such provisions or This permit shall be STATE LIC.
deemed revoked. WATER HEATER D UCENSE NO. QQ CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO ROCESSED BY
1 hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM (92 OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVERrel >'
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM a
FINAL / / VALIDATION O
License Number Lic. Class C':56" DATE
C
� /�� FINAL �(/� O
Contractor Dote-LlL=1-743
❑ W
oxempt under Sec. N
2
B.8 C. for this reason Plan check fee ,
Dole: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant
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 8 O.5 A
Professions Code): City Tel. No.
❑ o v o 0 0 5
as owner of the property, will do the work and the
s pop.
CONSTRUCTION
is not intended or offered for sale (Section u - 7 E 5
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY ,nr" ' 7 E 2 5
1 hereby affirm that there is a construction lending agency for F S—F
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 that the 1110.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 'onecl prop fo inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
I !may 83
Si Lure of Perms tee Date