HomeMy Public PortalAbout9209 LAS TUNAS DR_Plumbing__ WORKER'S COMPENSATION DECLARATION 20-0026 DPW 9/89 APPLICATION FOR PLUMBING PERMIT
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, I,hpreby affiem•,that•I have,a certificate of consent to self insure,
or a certificate of,-Worker's Compensation Insurance, or a certified
i copy 4hereofj(Se903800 Vaa0116)�; i•t 1}+',•:(�, _ \ .a
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS' ' DEPT. OF PUBLIC WORKS DIV.
Policy�No' Company
❑ Certified.copy,is-hereby furnished y
{� ,. t,` s'+ _FOR APPLICANT TO FILL IN(PRINT OR TYPE)- BUILDING a f J�
❑ w t ADDRESS - z-O' -,(�. I�l/lS O�
Cert Pied'copy is filed witti ifie couhty`building uispection
department, ,;ti�iM1, s.y,t;" v,:• r_7; NUMBER FIXTURE OR ITEM @FEE ;L'OCALITY
Date ��Applicant r WATER CLOSET _
7 D NEAREST
� - .•'�a a•:�,�„ �51 i�?* 3� � � CROSS ST.
CERTIFICATiE�OF;EXEMPTIONtlFR-M,WORKERS' BATH TUB
til s
GOMPENSATIONFINSURANCE - ASSESSOR
-"`• "'�" � - - MAP BOOK PAGE PARCEL
(This section needhnotkbe completedyif;the�wyork Involved by the SHOWER -
permit is for one huridyed dollars($100)orr!ess.) OWNER
LAVATORY- -
I certify that in the performance of-the work ,for�which this permit a
is issued, I shall not employ any person•in any manner so as to SINK - -,� ADDRESS D4 '
become subject,to the'Workers'Compensation Laws
DISWASHER '
Date Applicant � CITY -•TEL�NO
Y CLOTHES WASHER CONTRACTOR
NOTICE TO APPLICANT-'If,' after making this Certificate of
Exemption,you should;become subject to the Workers' Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions of the-Labor Code, you must forthwith comply with such
provisions,or this pg[mt shall,be deemed'rrevoked' LAWN.SPRINKLER SYSTEM `
LICENSED CONTRACTORS DECLARATION CITY TEL NO
l,'`r' "` R, IL
I hereby affirm that'I amelLcens'ed under provisions of Chapte •WATER HEATE
r 9, ,
(commencing witH`Sectiori 20b0) of Division 3 of the Business and •y z•. STATE LIC O
GAS SYSTEM'^ OUTLETS LICE0 EINO CLASS (�
'Professions:Code;ay my license,is•m full force"and effect -..^ K r� F
,OUTLETS OVER -.,� DISTRICT NO PROCE D BY
-5 PER SYSTEM 0
License Number Lic Class — `f F'
FIATE CL VALIDATION W
�i D
Contractor• s Date $$fr_ CL
,nk' "
tam exempt under Sec jF61yN , � Z
B&P C for tH&reai;dri' s' f
Plan check,fee _ a Z �'
Daw
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ry' , .7 O `sly (?rci
Signature PLUMBING PERMIT ISSUING FEE'$, �L�
a. I ?IeTEM ,r•'
❑ _ TOTAL FEE _ �TtaTIAL ��2�.�
,SINGLE FAMILY Plan check applicant 3 -
HOME OWNER-BUILDER DECLARATION Name
�rilGll�'�l
I hereby affirm that I am exempt from the Contractor's License Law L�1��t�Y���'������
for the following reason,(Section 7031 5, Business and,Professions Address _ G!l'f11�VG �;I it
Code) s '
= v City Tel
1,7asbwner of the property,will do,the work and the structure y-�;y�;yi
is not mtend'ed,or',offered'foi sale (Section 7044, Business h�(��`I�i1t11'
o.ar
and'Professon's Code) 4.
'�:CONSTR�UCTION'LENDING AGENCY � .
" I•hereby affirm that>thereyis a construction lending agency,for the
periormance.of the work for which'rt�is`permit is'is'sued.(Sec 3097,
Civ C) l
Lender's Name
Lender's Address '
I certify that I have read this„applwation and state that the-above
information is correct I agree'to comply with all County ordinances ,
and State laws-regulating Plumbing, and hereby authorize-
representatives of this County to enter upon'the above-mentioned
property foryirispecfion purposes t SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Pd'iTo tiee .Date �'