HomeMy Public PortalAbout10405 LA ROSA DR_Plumbing__ TION
WORKERS'that
t I have
a certificate
of corse APPLICATION FOR PLUMBING PERMIT
I hereby affirm shot I have a certificate of consent to self 76g6E1A
insure, or a certificate of Workers" ompensallon Insurance, CE 817(REV. 10/81)
or a c re ied cop t regf,,(,�c. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
b-0�l —00—J /TT7
P❑ol�icy o. Company
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING O 1/O
®" Certified copy is filed with the cou. building inspe<- ADDRESS
lion depLA k0SA
artment. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
�3 60LWATER CLOSET '�
Date / Appl i4ant NEAREST qgOAW
CERTIFICATE OF EXEMPTIOROM WORKERS' ' BATH TUB OD CROSS ST.
COMPENSATION URANCE SHOWER ' 6 OWNER - r.
(This section need not be cam. d if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) 3 LAVATORY ADDRESS 9LQjQ u
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner ' SINK CITY / L T"O,
so as to become subject to the Workers Compensation Laws. DISHWASHER O 7�`
CONTRACTOR �GJ
Date Applicant CLOTHES WASHER ADDRESS f CY
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY TEL NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM r
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS C36-2 1
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9GAS SYSTEM OUTLETS nO
(commencing with Section 7000) of Division 3 of the Business OUTLETSOVER
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL
d
. _ VALIDATION
License Numberan� ��/ LIc. ClassDATE v
FIN
Contractor Date
i i BY AL
❑ W
I a empt under Sec. N
B.8 . for this reason
Plan check fee ►
Dale:
PLUMBING PERMIT ISSUING FEE$ _
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
�2 7 9 8 A
Low for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. _ it o e m e o 5
❑ I, as owner of the property, will do the work and the C 0 0 9 625
structure is not intended or offered for sale (Section ,
7044, Business and Professions Code). 0 u 0 9 6 2—r m
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for 0 6 1 5—8 3
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 ,
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authoac
enlatwes of this Counly to enter upon the
aboved proper r ' spection purposes._ s. SEE REVERSE FOR EXPLANATORY LANGUAGE
SignatK a of Perri Date