HomeMy Public PortalAbout8854 LONGDEN AVE_Plumbing__ WORKERS'COMPErNSAYION DECLARATION. GaPG'd9C�o 0 0
Q`�0®�1 FOP, pLNJM8HO PERMOT
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 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
tion department. NUMBER FIXTURE OR ITEM a FEE LOCALITY
WATER CLOSET
Date Applicant / NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER ! U OWNER•\,
(This section need not be completed if the work involved by MAIL r�
the permit is for one hundred dollars ($100)or less.) LAVATORY / ADDRESS U1
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO..2,47_,J-1 6
so as io become subject to the Workers'Compensation Laws. DISHWASHER
�J CONTRACTOR
Date ✓ �`� Applicant42A CLOTHES WASHER ADDRESS
�
NOTICE TO APPLICANT: If, after making is Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth-
LAWN SPRINKLER SYSTEM CITY TEL. NO.,2F7-,r-/,(7
with comply with such provisions or this permit.shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRIcNO._ ,./ PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS S` UQy
c
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and"Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINA
DATE �� LIDATIOW y:
License Number Lic. Class 0.'
O
FIN - U.
Contractor Date B
El
Ch
I am exempt under Sec.
U
B.BP..C. for this reason W
S a7_�,6 Plan check fee
Date: D
PLUMBING PERMIT ISSUING FEE$ ! Z
Signature
TOTAL FEE //11 •77 y
Plan check applicant # �` 17 6
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name ,o is 2 5
I hereby affirm that I am exempt from the Contractor's License Address o 0 9.2
$5 v
Law for the following reason (Section 7031.5, Business and 9 2 s$8
Professions Code): City Tel. No. O
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section D
7044, Business and Professions Code).
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 D
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
aqve-mentioned property for inspection purposes.
�1 p/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature V Pe mittee Date