HomeMy Public PortalAbout9177 LAS TUNAS DR_Plumbing__ WORKERS:COMPENSATION DECLARATION
20-0026 DPW,4/87 APPLICATION FOR PLUMBING PERMIT
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• I Hereby-:af!irm that I have a certificate of consent to self m- 76A667A
sure,oro tertiftcate of-Workers'Compensation Insurance,ora CE 817(REV 8/86)
cerhfred'Copy hereof (Sbc 3800, Lab
C/� COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Po1Ecy No �Company
Certified-co py is hereby furnishe }
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS
de a,trnent NUMBER FIXTURE OR ITEM tvla FEE LOCALITY,
Date' y ��.Applicant � WATER CLOSET(TOILET) �� NEAREST
BATH TUB CROSS ST
CERTIFICATE OF EXEMPTION FROM'WORKERS'
COMPENSATION INSURANCE SHOWER OWNER L
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100) or less.) LAVATORY, Q ADDRESS ,- Aa� 11
I certify that in the performance of the work for which this per- 1
mt is issued, I shall not employ any person in any manner so SINK CITY n TEL
a
as to become subject to the Workers' Compensation Laws, DISHWASHER
CONTRACTf
Date Applicant CLOTHES WASHER
O
NOTICE TO APPLICANT If, after making thi"s CertificateADDRES �of Ex- - +
emption,you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR /
/
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM CITY TEL
ly with such provisions or this permit shall be deemed revok- �' STATE, UC � ��O G
l
ed I WATER HEATER LICENSE NO --797 CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affirm that'I am licensed under provisions of Chapter GAS SYSTEM OUTLETS U A_
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL .2 9/ VALIDATION
fect 2p G/ O //
License Number)/ ��� ( Lic Class(--/3- Y �� oU DATE U
Contractor ' Date o ' BYFINAL_
v O
H
I am exempt under Sec U
W
B 8P'C for this reason
a
' Plan check fee Poo. � Z
Date PLUMBING PERMIT ISSUING FEE$_ �d
Signature• TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant t, $
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 ITEM
1, as-owner of the property, will do the work and the City Tel No �f�={�`
structuie'is not intended or offered for sale(Section 7044,
113 00
Business and Professions Code) � ve_fI
L'f�� l
CONSTRUCTION LENDING AGENCY pool t � �Lj a I;J
I hereby affirm that there_isa'construction lending agency for
the performance of the work for which this permit is issued
(Sec 3097, Civ C ) '
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Lender's Name 71-�+G I P l•4 cl�
Lerider's Address-
I certify that,I hove 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
uthonze representatives of this County•to enter upon the
bo e-mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee —1 Date