HomeMy Public PortalAbout8848 LONGDEN AVE_Plumbing__ WORKER'S COMPENSATION DECLARATION 720-0026 6A667APW9/89 AI>✓Ir'UCQMN FOR PLUMBNG PERNT
I hereby affirm that I have a certificate of consent to self insure, u
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 1. .
❑ Certified copy is hereby furnished.
EJ Certified
APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS
department. - NUMBER FIXTURE OR ITEM @ FEE LOCALITY – '
P
Date Applicant WATER.CLOSET NEAREST /
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. PAO7
COMPENSATION INSURANCE ASSESSOR t
(This section-need not be completed if the-work involved by the SHOWER MAP BOOK �'P PA_GEOc::91 PARCEI_d" 4
permit is for one hundred dollars($100)or less.) OWNER
I certify that in the performance of the work for which this permit If yqn"N
LAVATORY
is issued, I shall not employ any person in any manner so as to SINK MAIL
become subject to the Workers'Compensation Laws. t ADDRESS
DISWASHER CITY P TEL.NO.
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR
Exemption,you should become subject to the Workers' Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO. }
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER
(commencing with Section 7000 of Division 3 of the Business and STATE LIC.
( 9 ) LICENSE NO. CLASS V
Professions Code,and my license is in full force and effect. GAS SYSTEM / OUTLETS
OUTLETS OVER DISTRICT NO. (7—�+Y'e PROCESSED BY O
5 PER SYSTEM iy %t% �
License Number Lic.Class C
FINAL .....A..'.. ......._...'V.AILIOATION �
DATE C t% ,A .__ . s
Contractor ` Date L ._. .- _7_ _ ., _r,- co
❑ r FINAL - -"D 121 u t�z
1 am exempt under Sec. j BY
B.&P.C.for this reason
Plan check fee st '`38 �
Date: i =IAL 13a_r a ��
PLUMBING PERMIT ISSUING FEE$
. r~ `
to � 4:������ �1�__i
Signature _...... .... .. ._ ,_..
TOTAL FEE ��. o� (� '.�"It�1`It3E ,13 t
❑
SINGLE FAMILY Plan check applicant
HOMEOWNER-BUILDER DECLARATION Name 'i'�
I hereby affirm that I am exempt from the Contractor's License Law L lf11,l_lI
for the following reason (Section 7031.5, Business and Professions Address
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 r-
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 D
and State laws regulating Plumbing, and hereby authorize
representatives of this County to enter upon the above-mentioned
' property r insp ction urpos s.
� SEE REVERSE FOR EXPLANATORY LANGUAGE
�,- -
gnature of Permittee Date