HomeMy Public PortalAbout8919 LONGDEN AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION20-00 APPLICATION FOR PLUMBING PERMIT
I here b affo-favthat I have a.certificate of consent to self in- 76A666 DPW 4/87
Y�� 76A667A �tIILJIII
sure,or certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86)
certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company :&fAtE F-J W-y COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby furnished.
.FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING pl
Certified copy is filed with the county building inspection ADDRESS Lo M p-N
department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date Applicant WATER CLOSET(TOILET) NEAREST.
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.' SG E2 f= c�
COMPENSATION INSURANCESHOWER OWNER /?��r�'U�Q�- �j9itfz-,:—C, I
(This section need not be completed if the work involved by MAIL Q
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS �-J
Qiv
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so SINK CITY L 6�(�l C i t�f TEL. NO. 2g7 �
as to become subject to the Workers' Compensation Laws. DISHWASHER
CONTRACTOR t O 1S IPLAS.%l Bf U
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS
emption,you should become subject to the Workers'Compen- SWIMMING. RECEPTOR • 1
sation provisions of.the Labor Code,•you must forthwith)com CITY t��� 1 TEL. NO. (�'
p y P- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE Cf LIC.
ed. WATER HEATER LICENSE NO. 7 (3• S CLASS
1 . LICENSED.CONTRACTORS DECLARATION' DISTRIC f NO O P ESS Y
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 2
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL jCl VALIDA ION
fect. �,—�� DATE vl1 ,J
License Number 7 7���J Lic. Class C� 7 0
Fl NAL,11�q; U 0
Contractor Date BY ccO
a-
I am exempt under Sec. U
LU
B.BP.C. for this reason 0.
- ` .d Plan check fee ► ! $
Date: 4r. PLUMBING PERMIT ISSUING FEE$ 103
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Signature '� i
TOTAL FEE50
SINGLE FAMILY Plan applicant
HOMEan ceca
OWNER-BUILDER DECLARATION Pp c
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1 hereby affirm that I am exempt from the Contractor's License Name
L.w'for the following reason (Section 7031.5, Business and
s'' °Y
s
Professions Code): Address
-p ;y c
:rig;t! itl e.}7-tt
1, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044, 1 ITEMS
EMS
Business and Professions Code). 5-
CONSTRUCTION LENDING AGENCY , TOTAL ��® _e�
I hereby affirm that there is a construction.lending agency for CHECK 20.
theerformance of the work for which'this ermit is issued 1'
(Sec. Civ. C.).
p •HAht, ,I!i!
Lender's Name
�'IO 00-0001 1110/90
Lender's Address'
8189 1 AM!'
1 certify that l have read this. application and state that the
above information is correct. I agree to comply with all County ►
ordinances and State laws reg, Ipting Plumbing, and hereby
authof•ze representatives of/thy*s County to enter upon the
above mentioned property for lnspoction purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
c�_,4iat6re of Permittee Date