HomeMy Public PortalAbout10440 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)
or a certified copy thereof�°��Sec. 3800, Lab. C.I COUNTY OF LOS ANGELES ,,� BUILDING AND SAFETY
QiO�N1o. C6mpany � � to,-# 16clYO
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is Filed with the county building inspec- ODRE85
Lon department. NUMBER FIXTURE OR ITEM C6 FEE LOCALITY
Date Applica nt WATER CLOSET _14a J2 00NEAREST
CERTIFICATE OF EXEMPTIO ROM WORKERS' BATH TUB OC7 CROSS Si.
COMPENSATION r4JURANCE SHOWER OWNER AMR _ aWf
(This section need not be comp) d if the work involved byMAIL J /
the permit is for one hundred dollars ($100)or less.) LAVATORY
I certify that in the performance of the work for which this ADDRESS !/
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permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO.
so as to become subject to the Workers Compensation Laws. DISHWASHER
00 CONTRACTOR
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESSI C.
Exemption, you should became subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY8L n10dZE TEL NO.
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATELIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION CDISTRICT NO. 011TOCESSED BY
I hereby affirm that 1 am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETSt:iao
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(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
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and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL Q IL
DATE I�—alle-p VALIDATION u
License Nu er VV Lic. Class
FINAL v. O
Cora
ntctor Date OO BY ~
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I a empt under Sec. 3
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8.8' . for this reason plan check fee Z,
Date: PLUMBING PERMIT ISSUING FEE$ 0
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY 1=2 8 0.2 A
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address o o a e o 5
Low for the following reason (Section 7031.5, Business and ,
Professions Code): City Tel. No. 2 0 - 7825
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sole (Section ► '° " o 711 2 5 5
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 0615-83
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- t' red pr rt for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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nature of Permit es Date