HomeMy Public PortalAbout10420 LA ROSA DR_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
hereby affirm that I havecertificate of consent to self 81 (7.
insure, or a certificate of Workers'
CE BV kers' Compensation Insurance, CE (REV. 10/81)
a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
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cy,No ," '_ ( ,'Company 11 )11, '. ,j Z L "i` O -D
Certified copy is hereby furnished. ' BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS - 4i
Certified copy is filed with the county building..jPspec-
tion department. i \ NUMBER FIXTURE OR ITEM Q FEE
LOCALITY
Date�/ "� �' Applicant -"y' r 'y d WATER CLOSET r' NEAREST
CERTIFICATE OF EXEMPT( ROM WORKERS BATH TUB ?�
CROSS ST.
11
COMPENSATIONF URANCE ` SHOWER 1 OWNER 'N+
(This'action need not be comple od if the work involved by
MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY � :+1
(-,r ADDRESS !f
I certify,that in the performance of the work for which this
sopermit is issued, I sholl not employ an person in an manner SINK �l. (.� CITY <c TEL NO
as to become subject to the Workers'Compensation Laws. ' ! i
DISHWASHER �� �y CONTRACTOR
Date Applicant CLOTHES WASHER r - � ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY
Compensation provisions of the Labor Code, you must forth- TEL. NO.
LAWN SPRINKLER SYSTEM 1 p t
with comply with such provisions or this permit shall be STATE UC.
deemed revoked. WATER HEATER I . ., 1 LICENSE NO. f% 1 CLASS
LICENSED CONTRACTORS DECLARATION PDAT
. DISTRICT NOr ROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS -�"
�1
a Y
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER' n n m tic nse is' ff t5 PER SYSTEMand Professo s Code o d e m full force and a ec.y L g VALIDATION O
License Number j Lic. Class /_�^ W
[ FINAL J
Contractor r •' 1 Date {�"I (+)J BY Gjgrp�j-BIn
p Y
am xempf under Sec. �G '7 Q
B.8 .C. for this reason O
Plan check fee a
Date. PLUMBING PERMIT ISSUING FEE$
L l W
Signature ~'
TOTAL FEE /
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name 'a
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and "'• 7; ' p'
Professions Code): City Tel. No.
17
I, as owner of the property, will do the work and the � -
structure is not intended or offered for sale (Section
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 Name
Lenders Address
I certify that I-have read this application and state that the ►
above information is correct. I agree to comply with all Cobnty
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above- ntioned perty,for inspection purposes.
J p ar SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ature of Permittee r Date