HomeMy Public PortalAbout5752 LOMA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby 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 certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES / 7 BUILDING AND SAFETY
Policy No. Company
❑ Certified copy is hereby furnished. _
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS 57-5-Z dam7
14
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant WATER CLOSET NEAREST -•�
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. / U a'!
COMPENSATION INSURANCE SHOWER OWNER ;gaJ,e.WC&
1 (This section need not be completed if the work involved by MAIL ��
/I the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS��cj //o oav,, -
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner r SINK CITV1C� lG` 0fr TEL. NO��^ 5
so as to become subject to the W kers"C ensation Laws. DISHWASHER GG /`G
/� CONTRACTOR /1 ��
Date/4f6_3 Applicant 'e'`''ee__-_ CLOTHES WASHER ADDRESS3/,q CJ � �„+/N
NOTICE TO APPLICANT: If, afte< aking this Certificate of w
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR �+ l
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY /b, �� _ TEL. NO.Vl13_ 7
with comply with such provisions or this permit shall be STATEN /yc/ � / LIC. Q y�
deemed revoked. WATER HEATER LICENSE NO."0— (/( // CLASS P
LICENSED CONTRACTORS DECLARATION DISTRICT NO. P OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS T �o V
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
�f' DATE VALIDATION �
License Numbeec_: 0&1 Lic. Class f
FINA
Contractor Date BY
❑ I am exempt under Sec. Cy
B.&P.C. for this reason 111110.Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ L?
Signature
TOTAL FEE
Plan check applicant %� ? 9 F
SINGLE FAMILY -
HOME OWNER-BUILDER DECLARATION Name 0 c
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and „ LL Q,J C,
Prof ssions 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). , ) �!. n 6
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
authorizerep entatives of this County to enter upon the
abov - e ed property forinspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
atu f Permittee Date