HomeMy Public PortalAbout10634 LIVE OAK AVE_Plumbing__ ' WORKER'S COMPENSATION DECLARATION 20-0026 DPW 9/69
76A667A APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec 3800 Lab C)
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
Policy No Company
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Certified copy is hereby furnished
❑ _ Q L
Certified'copy is fled with the county building inspection FOR APPLICANT TO11 FILL IN(PRINT OR TYPE) BUILDING
S
department NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant WATER CLOSET NEAREST
BATH TUB
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the
SHOWER MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) LAVATORY -. OWNER `?
I certify that in the performance of-the work for which this permit MAIL K�
is issued, I shall not employ any person i any manna so as to SINK ADDRESS �'
become subject to the Workers' C
omp
.
nsat n Laws `
DISWASHER CITY iA� TEL NO 1
Date Applicantiawl CLOTHES WASHER _ /T J (r9
NOTI E TO APPLICANT If, after making this Certificate of CONTRACTOR f/ /N�
'Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR J
provisions of the Labor Code, you must forthwith comply with such ADDRESS U7
provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM I6v
LICENSED CONTRACTORS DECLARATION CITY TEL NO r
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER COT L
TATE LIC
(commencing with Section 7000) of Division 3 of the Business and LICENSE NO � qj CLASS �� 0
Professions Code, and my license i in full force and effe t GAS SYSTEM OUTLETS d
OUTLETS OVER DISTRICT NO PROCESSED BY O
5 PER SYSTEM ' O Y i
License Number Lic_ Class O ~
FINAL V
r DATE�� ;�� VALIDATION nw.
Contract r ate fn
❑ �d ��o' FINAL Q Z
� I am exempt under Sec BY L
B&P C for this reason _
Date Plan check fee
Signature PLUMBING PERMIT ISSUING FEE$
❑ TOTAL FEE
Plan check applicant _
SINGLE FAMILY _
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law i A C1 ,14
for the following reason (Section 7031 5, Business and Professions Address �.
Code) - a3 D,
RI I,as owner ofithe property,will do the work and the structure City Tel No i iTEE r,�=
is not intended or offered for sale (Section 7044, Business _
and Professions Code) 6 0_AL 20 = 50
CONSTRUCTION LENDING AGENCY - a'li.i.
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)
Lender's Name
Lender's Address `t-i52 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 authorize
n representatives of this County to enter upon the above-mentioned
property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE