HomeMy Public PortalAbout10465 LA ROSA DR_Plumbing__ Wi)RKERS'COMPENSATION DECLARATION 7fip887a APPLICATION FOR PLUMBING PERMIT
1 hereby affirm that I have have certificate of consent to self ce en (z-eo)
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy there f(Sec. 3800, Lab.C.) i
/Z -0O^�+�/LTJ � �µ COUNTY OF LOS ANGELES 7' BUILDING AND SAFETY
o icy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING O
ADDRESS
I� Certified copy is filed with the county uildin in p t' n NUMBER FIXTURE OR ITEM • FEE
Lf�
department. LOCALIT
CLOSET
Date�� yZ- Applicant NEAREST
BATH TUB �-v CROSS ST. A61_tac:L�
CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE SHOWER OWNER
LAVATORY MAIL�
(This section need not be completed if the work involved ADDRESS a,
by the permit is for one hundred dollars (5100) or less.) SINK �-� CITY - TE NO. OU
Z
I certify that in the performance of the work for which this DISHWASHER O
permit is issued, i shall not employ any person in any manner CONTRACTOR
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER p V ADDRESS ~
ZZ.o S t
Date Applicant SWIMMING POOL RECEPTORr y
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL. NOS-75, y
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATEpp //ff LIC. z
Compensation provisions of the Labor Code, you must forth- WATER HEATER Qb LICENSE NO. yev CLASS
with comply with such provisions or this permit shall be
771
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. P OCESSEDBY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER 3!o d
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi. FINAL —�� VALIDATION
ness and Professions Code, and my license is in full force and DATE
effect.
6 a C 3 �i FINAL
License Number Lie. Class —gy (itrt�
Contractor 19VDate =[S _ v
El I am exempt from the licensing requirements as 1 am a
Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ Q'v
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE Q DD
Lie.or Reg.No. Date LN.me
heck applicant
HOME OWNER-BUILDER DECLARATION R50Q1A
I hereby affirm that I am exempt from the Contractor's ess
License Law for the following reason Section 7031.5, Busi- # ao e o 0 5
( Tel.No.
ness and Professions Code):
ElI, as owner of the property, am exclusively contracting Q o - 40.00
with licensed contractors to construct the project 000400050
(Section 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 0 4,28-8 1
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 SEE REVERSE FOR EXPLANATORY LANGUAGE .
ordinances and State laws regulating Plumbing, and hereby
oWizer� atives of County to enter upon t e
apetty i pectin purpose S.
Signature of Permittee Date