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HomeMy Public PortalAbout10425 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 B17(REV. 10/81) or a certified copy thereof S&c. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY a�Ro.O©'° 19� 7�ny LWk3c�S13� Ilrf Certified copy is hereby furnished. �--1' FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING y�T Certified copy is filed with the cou t building inspec- ADDRESS tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY G L Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTIO ROM WORKERS' BATH TUB OD CROSS ST. COMPENSATION N URANCE SHOWER O OWNERrnU P (This section need not be comp) t d if the work involved by MAIL the permit is for one hundred do lots ($100)or less.) LAVATORYQO ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner } SINK DD CITY L TEL. NO. so as to become subject to the Workers'Compensation Laws. DISHWASHER to 0-0 CONTRACTOR Date Applicant 1 CLOTHES WASHER 10 OO ADDRESS -011 �/� NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM �~ with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER .�'sV LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION � DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER 1 ! and Professions Code, and my license is in full force and effect. 5 PER SYSTEM 1• FINAL S QrnL (j DATE j_ . VALIDATION V License Number�30 5`700 Li,. Class r K / `' C FINAL r A^�-l� V Contractor �(,�e_Date rn�/7'�a S- BY ` P ❑ W a I a xempt under Sec N B. .C. for this reason Z Plan check fee Date: Signature PLUMBING ' PLUMBING PERMIT ISSUING FEE$ 0 TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name 2 8 0 0 A I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Address o e a e a cj Professions Code): City Tel. No. 2 0 a 7 8 2 5 ❑ I, as owner of the property, will do the work and the structure is not intended or offered for saleSection , n r x 7044, Business and Professions Code). ( o.° 7 2`� CONSTRUCTION LENDING AGENCY 0 6 1 5—8 3 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-m tinned prop ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sig tune of Permittee ZL �Date SI9J —�--