HomeMy Public PortalAbout10335 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, CE817(REV. 10/81)
or a/a certified copy therreeof (/Seek. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
P❑aIcy Nio?"00 '(7,s 1Company
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS 1416!1ASS
tion department. NUMBER FIXTURE OR ITEM en FEE LOCALITY
Date -�y-B�Appli4ant WATER CLOSET v NEAREST TfimL G
CERTIFICATE OF EXEMPTI FROM WORKERS' BATH TUB
CROSS ST.
COMPENSATIO I SURANCE OWNERM)g J
SHOWER
(This section need not be comp ed if the work involved by MAIL q
the permit is for one hundred dollars ($100)or less.) LAVATORY 'ADDRESS
I certify that in the performance of the work for which this al
permit is issued, I shall not employ any person in any manner J SINK �� CITY Pd TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER 00 �l
CONTRACTOR '
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS
IKJ
Exemption, you should become subject to the Workers' SWIMMING OL RECEPTOR I
Compensation provisions of the Labor Code, you must forth- CITY car TEL. NO.
LAWN SPRINKLER SYSTEM JCS J'
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. Q CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business1 OUTLETS OVER �s� n
and Professions Code,and my license is in full force and effect. 1 5 PER SYSTEM FINAL /��� �yJ VALIDATION V
3 DATE s!i
License Number 395900 Lic. Class W
FIN
Contracto AaLAVLDate
([Li yip BY AL
W
I om empt under Sec N
6.8P. . for this reason , Z
Plan check fee
Date:
' PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant 127 9,4 A
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name fr " °,° e a 5
I hereby affirm that I am exempt from the Contractor
s License Address ° ° 96 2 5Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. ° ° ° 9 6 25 V
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section , 06 1 r-83
7044, Business and Professions Code).
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 Nome
Lender's Address
I certify that I have read this application and stole that the ►
above information is correct. I agree to comply with all County
ordinances and State lows regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned pro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
43
Si azure of Permittee Date