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HomeMy Public PortalAbout9216 LIVE OAK AVE_Plumbing__ WGRKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm- that I have a certificate of consent to self 20-0026 DPW 6/87 insure, or'a certificate of Workers' Compensation Insurance, 76A667A dr a certified copy thereof (Sec. 3800, lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company Certified copy is hereby furnished. FOR APPLICANT.TO FILL IN(PRINT OR TYPE) BUILDING /� L Certified copy is filed with the county building inspec- ADDRESS 2 l� E K tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY —re/Ll r� Lis cl if Date Applicant Z WATER CLOSET D NEAREST l CERTIFICATE OF EXEMPTION FROM WORKERS' 2 BATH TUB CROSS ST. IT L;'V L� N A COMPENSATION INSURANCE SHOWER OWNER , EIV (This section need not be completed if the work involved by i MAIL the permit is for one hundred dollars ($100)or less.) ✓ LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO. 2^ so as to become subject to the Workers'Compensation Laws. DISHWASHER •7D CONTRACTOR Date Applicant CLOTHES WASHER /O ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM ,tom with comply with such provisions or this permit shall be v STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION v DISTRICT NOD, PROCESSED BY ET TLS I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OU (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and m license is in full force and effect. 5 PER SYSTEM Y FINAL DATE VALIDATION E �� License Number Lic. Class 2 O +� Q FINAL Contractor Date BY I am exempt under Sec: J� o', B.&P.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ CO Signature r JET- TOTAL FEE a r- 1s Plan check applicant q__- SINGLE FAMILY _;_:: ? j HOMEOWNER-BUILDER DECLARATION Name - t I hereby p affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and " Professions 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). lop CONSTRUCTION LENDING AGENCY 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 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 representatives of this County to enter upon the above-menti ed property for inspection purposes. va7��_ `© SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o-Perrr ee Da