HomeMy Public PortalAbout6209 LOMA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I reby airm-that I have a certificate.of consent to self 76A667A
r.insK � ct a certificate of
Workers' Compensation Insurance, CE 817(REV. 10/81) u
or a certifi copy thereof(Sec. 3800, Lob. C.) .t COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Id Company
Certified copy is hereby furnished., -
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING /*
ADDRESS
Certified copy is filed with the county buildin inspec- �a E
tion'department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
a' ( WATER CLOSET NEAREST ��
Date Applicant
- CERTIFICATE OF EXEMPTION FR M WORKERS' BATH TUB f CROSS ST. { 'v
COMPENSATION INSURANCESHOWER /u OWNER' C ^� -L.WC '
IV
(This section need not be completed if the work involved by [/
MAIL
the permit is for one hundred dollars($100)or less:). I LAVATORY• ADDRESS
I certify
is that
in the
l shale not employofthework for which this �n p�^
permit'y p y person in any manner SINK CITY �L( ciZ� TEL. NO. 2 �'
so as to become subject to the Workers`Compensation Laws, DISHWASHER1,
CONTRACTOR --� 0 C ry, 1 C
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this-Certificate of SWIMMING POOL RECEPTOR � `
Exemption, you' should become subject to the'Workers'
Compensation provisions of the Labor Code,you must forth- LAWN SPRINKLER SYSTEM CITY �� Lz �t Z TEL. NO. '�7�
with ,comply•withsuch provisions.or this permit shall be STATE LIC. -
deemed revoked. WATER HEATER LICENSE NO. 2S �. CLASS
-LICENSED CONTRACTORS DECLARATION l DISTRIC .NO._ l P O SED BY
I hereby affirm that L am licensed under provisions of Chapter 9 I GAS SYSTEM OUTLETS l,Q� O(JX
(commencing with Section 7000) of,Division 3 of the Business OUTLETS OVER
and Professions Code,and my license'is in full force and effect. 5 PER,SYSTEM FINAL // VALIDATION
DATE �J/�} J` 1 d�
License;N,mber �2 Lic. Class
FIN 1 r U.
ContracDate '' B f
❑ Ix mot under Sec. O
B.BP.C. for this reason
Plan check fee N
Date: PLUMBING PERMIT ISSUING FEE$ Z
. Signature' '
TOTAL FEE
Plan check applicant
• SINGLE FAMILY ;2 52 2 7 A
HOME OWNER-BUILDER DECLARATION Name
#,o o.o o.0 5
1 hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and V- 0 4 a 5 0
Professions Code): City Tel No. _
'0004Q50�
❑ 1, 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).
CONSTRUCTIONLENDINGAGENCY
Thereby affirm that there is a construction lending agency for
the performance of.the'work for which this permit is,issued
(Sec. 3097, Civ. C.). 4'
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
outhorize'representatives of this County to enter upon the
above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
S' na re o ermittee Date