HomeMy Public PortalAbout10410 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(RFV. 10/81)
or,�as QcertifiedifLJo y thereof q(qeecg93800, la b1.yC�.)', COUNTY OF LOS ANGELES BUILDING AND SAFETY
Pa`icy"�6.' -05-1c tpdny L,(/�/*�S/^1 r,� GOT#/S 'd / /V
❑ Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS Q�
Certified copy is filed with the county building ins ec-
tion department. NUMBER FIXTURE OR ITEM C FEE LOCALITY
Date �' —87 Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTIO OM WORKERS' BATH TUB 00 CROSS ST.
COMPENSATION RANCE {JV OWNER
SHOWER
(This section need not be completed if the work involved by 00MAIL• /" / y�
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS J
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK QO CITY TEL. NO.
so as to become subject to the Workers Compensation Laws. DISHWASHER
00 CONTRACTOR UMIO _/
Date Applicant CLOTHES WASHER W ADDRESS
7 / A
NOTICE TO APPLICANT: If, after making this Certificate of [/
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- SPRINKLER SYSTEM CITY TEL, NO. 7
LAWN
with comply with such provisions or this permit shall be � STATE LIC,
deemed revoked. WATER HEATERA.t� LICENSE NO, CLASS
LICENSED CONTRACTORS DECLARATION 150 DISTRICT NO, JNZDICESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS Qy
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER 11/J
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM �J FINAL VALIDATION O
License Number 375900 Lic. Class G 3� DATE t^fZ��i 4. u
FINAL
Contractor Dote ��/� BY
C O
u
W
❑ a
I am mpt under Sec. w
8.8P. . for this reason Plan check fee , Z
Dote: O
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY x_2 8�,5 A
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's license Address 9625
Law for the following reason (Section 7031.5, Business and
Professions Cade) City Tel. No. u n r 96 2 5
❑ 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section , 0615-83
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 thi3 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
authorize representatives of this County to enter upon the
above-m tioned pro ty r inspection purposes.
��� SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ture of Permittee Date