HomeMy Public PortalAbout10415 LA ROSA DR_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76AM7A
insure, or a certificate of Workers' Compensation Insurance, CE 617(REV. 10/01)
or certified co y then f Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
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cy No. Company
Certified copy is hereby furnished.
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 Q FEE LOCALITY "�
Date. qq._Applicant WATER CLOSET 00 NEAREST �J
CERTIFICATE OF EXEMPTIO ROM WORKERS' BATHTUB O CROSS ST, RO
COMPENSATION URANCE SHOWER OWNER FAQ
(This section need not be comple ed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY 00 ADDRESS &Qg2
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINKCITY n/ L TEL. NO.
so as to become subject to the Workers Compensation Laws. DISHWASHER IC
(19 CONTRACTORLoora ./
Date Applicant 1 CLOTHES WASHER ADDRESS 7 W
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTORCIAO
Exemption, you should become subject to the Workers' CITY . TEL NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM �' A ��
with comply with such provisions or this permit shall be STATE a_ LIC.
deemed revoked. WATER HEALER to 00 LICENSE NO. 14 00 CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby offirm that I am licensed under provisions of Chapter 9 GAS SYSTEMIV OUTLETS
00
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full farce and effect. 5 PER SYSTEM r DANE �^ 0
VALIDATION/S90c� Lic. Class G.3V7
License Number 3 �'� ps
_ p FINAL "` C O
ro
COntracr Date�U' �.3— BY 0' U
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❑ W
' -in am empt under Sec. A.
N
B.RP.C. for this reason Z
Plan check fee ,
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY 2 7 9.9 A
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License 1`.f o e'c 1 - 5
Low for the following reason (Section 7031.5, Business and Address
Professions Code): City Tel. No. c 7 e 2 5
❑ I, as owner of the property, will do the work and the 0-0 0 782560
structure is not intended or offered for sale (Section 111111,7044, Business and Professions Code). 06 } 5i-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 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-mentioned pro ty or inspection purposes.
/Y �,3 SEE REVERSE FOR EXPLANATORY LANGUAGE
S' ature of Permnee Date