HomeMy Public PortalAbout9564 LA ROSA DR_Plumbing__ WORK,5RS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby,.,afftAat 1 have t to 20-0026 DPW 4/90
affirm ave a certificate oconseno sein 76A667A
sure,orU certificate of.Workers'Compensdtion Insurance,or a
certified copy thereof (Sec 3800 Lab C )
Policy No Company
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
,
Certified copy is hereby furnished
F-]
FOR APPLICANT TO FILL IN(PRINT OR TYPE) FADDRE
Certified copy is filed with the county building inspection s
department NUMBER FIXTURE OR ITEM @ FEE
Date Applicant WATER CLOSET(TOIL LAt1i
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB LL O COMPENSATION INSURANCE SHOWER - d�lC
(This section need not be completed if the work Involved by MAIL
the permit Is for one hundred dollars ($100)or less.) LAVATORY REVL rC t `r0 ADDRESS L6N
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so Q CITY � TEL NOg&333/-7 p
as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER v ADDRESS
NOTICE TO APPLICANT If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY TEL NO
sotion provisions of the Lab— rode, you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC
ed WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PR SSE
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS Q ,
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM
fect FINAL 'lo VALkffATION
HOSE BIB DATE
License Number Lic Class a
FINA�� O
Contractor Date BY V
Q
17 1 am exempt under Sec 0
B 8P C for this reason W
Plan check fee a
Date ca
PLUMBING PERMIT ISSUING FEE$ Z
Signature
TOTAL FEE
SINGLE FAMILY ,
HOME OWNER-BUILDER DECLARATION 'Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031 5, Business and
Professions Code) Address
1, as owner of the property, will do the work and,the City Tel No 05
structure is not intended or offered for sale(Section 7044, ACCT.s
Business and Professions Code)
CONSTRUCTION LENDING AGENCY _ pop. 123°90
1 hereby affirm that there-is a construction lending agency for 1 ITEMS
the performance of the work for which this permit is issued
(Sec 3097, Civ c ) TOTAL 123 - 90
Lender's Name CHECK 123.913
CHANGE e 00
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 lot- 0000-0001 5/23/96
ordi ances and Stat laws regulating Plumbing, and hereby
ho ize represe a Ives of this County to enter upon the 15`t<°i�t 1 FM 5+�9
bo -mention pr pe ty for inspection purpos
v � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signal r of ttee Date