HomeMy Public PortalAbout8816 LAS TUNAS DR_Plumbing__ WORKERS'COMPENSATION DECLARATION 76A667A
I hereby affirm that I have acertificate of consent to self cE an (a-.el APPLICATION FOR PLUMBING PERMIT
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING (/
ADDRESS p y ,-g / ,,114
Certified copy is filed with the county buildin inspection NUMBER FIXTURE OR ITEM • FEE
dep r �J LOCALITY
Date O Applicant WATER CLOSET NEAREST N G 6 , �.
I/ BATH TUB CROSS ST. zz
CERTIFICATE OF EXEMPTION FROM WORKERS' C
COMPENSATION INSURANCE SHOWER OWNER nr O ct
(This section need not be completed if the work involved LAVATORY MAIL .S Ca/
by the permit is for one hundred dollars ($100) or less.) ADDRESS }
SINK CITY TEL.NO. d
0
I certify that in the performance of the work for which this DISHWASHERU
permit is issued, I shall not employ any person in any manner CONTRACTOR " Lrl
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER
ADDRESS 0
(o O
Date Applicant SWIMMING POOL RECEPTOR U
NOTICE TO APPLICANT: If, after making this Certificate of CITY i L TEL.NO. _ tyl
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. N
Compensation provisions of-tFF��e Labor Code, you must forth- WATER HEATER LICENSE NO. CLASS Z
with comply with such IproXions or this permit shall be -
deemed revoked. DISTRICT NO. PRO SSED BY
GAS SYSTEM OUTLETS ff
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINALGY _ �s _po VALIDATION
ness and Professions Code, and my license is in full force and DATE
effect.
FINAL( ,Z,, elf---)
License Number Lie.Class BY
Contractor Date
I] 1 am exempt from the licensing requirements as I am a Plan Check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE 0 Q-6
Lie.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name 6-req C
I hereby affirm that 1 am exempt from the Contractor's Address S , eN
License Law for the following reason (Section 7031.5, Busi- Oily TeL No. 9(.el
ness and Professions Code):
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project
(Section 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 2 8 A
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.). # • • • 5
Lender's Name
Lender's Address
2 • •
I certify that I have read this application and state that the 1 000
F
above information is correct. 1 agree to comply with all County SEE REVERSE OR EXPLANATORY LANGUAGE . . ° 10005
ordinances and State laws regulating Plumbing, and hereby -
authorize representatives of this County to enter upon the - O 9. 8—8 O
above-mentioned property or inspection purposes.
Signator of Permittee Date