HomeMy Public PortalAbout9469 LA ROSA DR_Plumbing__ WORKERS' COMPENSA-TION'dECLARATION t
.20-0026•DPW 4/87. APPLICATION FOR PLU.MBIN:G PERMIT.
I kereby;'affirin thatj have a certifIcate•of:consent to self,in- 76A�7A •
sure,or a ceriificate�of.Workers'Compensation Insurance,-or'a CE 817(REV. 8/86). e ;
certified copy thereof.(Sec ;3800, Lab. C,.)*-,,,.
Policy No• Company. COUNTY OF•LOS ANGELES _-� t, DEPT.,OF,PUBLIC,WORKS•_ _1 L" • .
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'Certified,copy is hereby furnished
`' FOR APPLICANT'TO FILL IN(PRINT OR TYPE)' BUILDING
�'
Certified copy is•filed with the'county buildmg,.mspectiori ADDRESS' o
department; NUMBER+ .� 'FIXTLIRE.OR'ITEM @ FEE,-
' -LOCALITY
W
D Y " j ATER CLOSET(TOILET)
NEAREST: v
BATH TUB
CROSS ST ;
CERTIFICATE OF EXEMPTION FROM WORKERS' ;'.
" ,I COMPENSATION INSURANCE SHOWER ' OWNER -
This section need not be com feted ifthe'w•o'rk invoWed�b y �' ' `" Ila
- ',( P Y-.' � , - -
fh permit is-for ordollars ($16 )or less.) LAVATORY, 'ADDRESS41
>I'certif,y that'in'the performance of tF e work fo'r`which this per' r; a
' SINK r CITY' TEL_NO' '
issued, 14
I,shall not employ any person in any'r a ner'so z n —
as% become sublect to the Workers'•Compensation Laws 4 DISHWASHER e r
CONTRACTOR
licarit°�_n�i.t•SL� rTY1 CLOTHES WASHER' . r" ., _
NOTICE TO-APPLICANT "lf,after'making•thF`s Certrficate'of.Ex- - r ;5' ADDRESS'
Y r, is • . ' SWIMMING 00'01.'RECEPTOR
emphon;you should'become'sublect,to the%Workers'-Compen-. a -CITY EL.,NO'
sation•provisions of the Labor`Code,,�,you.must:forthwith-comp- LAWN SPRINKLER°SYSTEM
ly with such provisions or this permit shall be deemed'.revok- STATE LIC
pd, ,N - P,; ': WATER HEATER' _ ' LICENSE NO `CLASS c
;LICENSED CONTRACTORS�i DECLARATION; 'DISTRICT NO P!! 1- ESS BY r' '
I hereby gffi�m that I am licensed under'provisions of Chapter- GAS,SYSTEM OUTLETS ��
9(comr'e'cing with Section 7000)•of Division,3'of'the Business ' OUTLETS OVER
and•Professions Code,,and my license is•in•full force and ef- 5 PER SYSTEM FINAL / VA ATION D'
tett' i,' .. °' DATE [/ a
License Number Lit Class 4 "U,
FIN L Q
Contractor' D.
l. 1r
�. I am exempt under Sec W'
this reason r, # ®a N:'
Plan check'fee =' ' �' o.,e 3 4 5' 2E
l Date T PLUMBING PERMIT'ISSUING FEE-$ Q '� °.'O • 3.4;,5 0-=:
Signature x
TOTAL FEE O 9'1 9-
8 8
SINGLE FAMILY , 4 . :
HOME,OVJNER-BUILDER DECLARATION j Plan check applicant -
fi
1 hereby'affirm that-1•am exempt from the Contractor's License Name'' = �' •• �'' a i.':. -
•-Law for'the following',reason (Section 7031,'5,;Business and
Professions Code), ' Address-
'a
ddress' N
k I;'as owner of the property, will do the work and the Gty - Tel No.
`structure is not intended_or offered'for sale''(Sec_tion`7044, ' s
Business and Profess l a ns.Code,)
CONSTRUCTION LENDING AGENCY
I hereby affirm'that there:is a construction fending agency for,
the performance of'the work for.which this.pe'r'mitl is•issued
(Sec;3097, Gv -C )• , , t �: a,
si
L'ender's Name
L'ender's Address, ,
i "' '•.
.I certify that I liave read:'this application andstate that tF e
above,mfd�ination-is correct. I agree to comply with all County
ordinances and State laws regulating,Plumbing, and hereby p:
authonie representatives'of this'County to enter upon the
above,-mentioned property.for inspection.purposes.
n
SEE'REVERSE,FOR EXPLANATORY,LANGUAGE -
Signature of Permittee { Date • n' `,' '