HomeMy Public PortalAbout9826 LEMON AVE_Plumbing__ „ WORKERS' COMPENSATION DECLARATION 'APPLICATION FOR PLUMBING PERMIT
I', e41' y Affirm that I have a certificate of-consent to self 76A667A
insure or a certificate of Workers' Compensation Insurance, CE 817(REV 10/81)
” or a c�tified copy thereof (Sec 3800, Lab C ) COUNTY.OF LOS ANGELES BUILDING AND SAFETY .
Policy No_, Company ,
Certified copy is hereby furnished BUILDING
E 'Q
FOR APPLICANT TO FILL IN(PRINT OR TYPE), ADDRESS (J
Certified copy is filed with the county building inspec-
tion department NUMBER FIXTURE OR ITEM @ " FEE
LOCALITY
Date Applicant WATER CLOSET.' NEAREST r
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ►, '
COMPENSATION INSURANCE •OWNE
(This section need not be completed if the work involved by SHOWER
the permit Is for one hundred dollars ($100)or less.) LAVATORY MAIL
ADDRESS
I certify that.in the performance of the work for-which this
permit is issued,'l shall not employ any person in any manner SINK CITY TEL NO
so as'to become subject to the Workers',Compensatron Laws DISHWASHER
CONTRACTOR
Date 'Applicant CLOTHES WASHER ADDRESS,
NOTICE TO APPLICANT 'If, after making this Certificate of
Exemption, you should 'become subject' to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the'Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL,NO
with comply with such provisions or this permit shall be STATE CIC
deemed revoked ? WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT P ED BY
GAS SYSTEM OUTLETS l �,
.I hereby affirm that I am licensed under provisions of Chapter 9 _ • _ 1 �
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER 4
and Professions Code, and my license is in full force and effect 5 PER SYSTEM FINAL /J
DATE VALID ION u
License Number Lic Class mC
FINAL 0
Contractor Date BY U
' w
I am exempt under Sec 0.
- of
B 8P C for this reason 23825A z,
Plan check fee
Date # 0 0 0 e-05
PLUMBING PERMIT ISSUING FEE$
Signature TOTAL-FEE S I.- 0 1 650
Plan check applicant, o e o 1 6 5 0 s
SINGLE FAMILY
HOME OWNER=BUILDER DECLARATION Name 1 1 (� 8 6
I hereby affiPm that I am exempt from the Contractor's License Address r
Law for the following reason (Section 7031 5, Business and
�Prole stuns Code) city Tel No
I, 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
I hereby affirm that there is a construction lending agency for
the performance of the work forwhich this permit is issued
(Sec 3097, Civ C )
Lender's Name - K
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
ordinances and State jaws regulating Plumbing, and hereby °
authorize representatives of'this County to enter upon the - T
above-mentioned)opperty for inspection purposes
SEE REVERSE FOR EXPLANATORY'LANGUAGE '
Sign ture &Per i ee Date