HomeMy Public PortalAbout10430 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(REV. 10/81)
r a certified copy thereof e . 800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
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❑ yCertified copy is herebypfurnished. L'J /01/
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FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the count building it eo ADDRESS
lion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date ./4—Y'3 Applicant WATER CLOSET 0 NEAREST
CERTIFICATE OF EXEMPTIO ROM WORKERS' BATH TUB CROSS ST.
COMPENSATION URANCE OWNER
(This section need not ba<ompl d if the work involved by SHOWERAW x(/
the permit is for one hundred dollars ($100)or less.) LAVATORY MDDRESS
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I certify that in the performance of the work for which this
permit is issued, i shall not employ any person in any manner SINK CITY / TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER D
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS 9
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth-
TEL
SPRINKLER SYSTEM CITYSo. TEL NO.
with comply with such provisions or this permit shall be STATE �-}� LIC.
deemed revoked. WATER HEATER - LICENSE NO. VV CLASS (�
LICENSED CONTRACTORS DECLARATION DISTRICT Nc P ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 0
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM 1 FINALVALIDATION 0
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License Number Lic. Class ,� DATE,}�
FINAL 0
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Contractor Date �J BY CJ — ~
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I am empt under Sec N
B.8 . for this reason Z
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ (�
Signature
TOTAL FEE 5 �'2 8 0.3 A
SINGLE FAMILY Plan check applicant o 0.- - a 5
HOME OWNER-BUILDER DECLARATION Name 2 - - 7825
1 hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031 5, Business and o n o 7$2 J 6
Professions Code): City TeL No.
❑ I, as owner of the property, will do the work and the O 1 5 -83
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 Nome
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
abov -me ' ned prop for nspection purposes.
C &a y �3 SEE REVERSE FOR EXPLANATORY LANGUAGE
Siglure of Permitee Date