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HomeMy Public PortalAbout9139 LAS TUNAS DR_Plumbing__ j ji WORKERS'COMPENSAVON DECLARATION APPLICATION FOR PLUMBING PERMIT 4 �#1 hexby,affirm that I,hoye a certificate of consent to self 20-0026 DPW 6/87 insur2, or of,certificate of Workers' Compensation Insurance, 76A667A or,a certified-copy thereofSec. 3800,, Lab. C-.)) .g COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS ' Po y Nafa.�(.Zay��Blf'IbBo,any r/�`F 1N$r I VENe-Y Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Q '�'^ - Certified copy is filed with the county building insp c- ADDRESS 113 ( J5 tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY L� Date '/~2-'_C, WATER CLOSET I Applicant CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars.($100)or less.) LAVATORY ADDRESS 396'7-15' E7 14111)4- RD, I certify that in the performance of the work for which this - permit is issued, I shall not employ any person in any manner SINK CITY f EM CQ L TEL. NC%1&J.r I76-Q y1 so as to become subject to the Workers'Compensation Laws., DISHWASHER C- I! ��11 LLV© wW CONTRACTOR , L t(,/67 Date Applicant CLOTHES WASHER ADDRESS 33 C r NOTICE TO APPLICANT: If, after making this Certificate of , ' -Exemption, you should become subject, to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY C TEPI � LAWN SPRINKLER SYSTEM with comply with such provisions or this permit.shall be STATE ��/� r LIC. deemed revoked. �J_ WATER HEATER l 1 LICENSE NO,.'�✓ !: O CLASS C__3 LICENSED CONTRACTORS DECLARATION s� J(l DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM c OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER , 0 ',.- _111_1 and Professions Code, ••��and my license is in full force and effect. 5 PER SYSTEM FINAL � VALIDATION O: /,o Lic. Class G r�fo DATE ✓ 0: License Numbe,-6- Pe j FINAL /1 Contractor 1�'-��-� ��4c e '� . '_' ° BY 0' ❑ Hi I am exempt under Sec. IIAS U B.BP.C. for this reason W Plan check fee ► Z Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE �- Plan check applicant SINGLE FAMILY J HOME OWNER-BUILDER DECLARATION Name _ I hereby affirm that I am exempt from the Contractor's License !t• ^ Address Low for the following reason (Section 7031.5, Business and Professions Code): City TeL No. ❑ 1, as owner.of the property, will do the work and the structure is not intended or offered for sale (Section ► � 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 1 herebyaffirm 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 NameED/� Lender's Acl&ess- /j6R MAW /,1) 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 f authorize representatives of this County to enter upon the above-m en ti oned'property fo inspection purposes. I 6�1/1r_w SEE REVERSE FOR EXPLANATORY LANGUAGE lei 4/ Signature VPermittee Date