HomeMy Public PortalAbout9127 LONGDEN AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION APPUCATpON FOR PLMMNNG PERMIT
I here* affirm that I have a certificate of consent to self 76A667A
nsore, or a certificate of Workers' Compensation Insurance, CE 817(REV 10/81)
.or a certified opy thereof,(Sec 380 ab C ) ^ �`i^ COUNTY OF LOS ANGELES. BUILDING AND SAFETY
Policy N��C mpa TAL � A,^4)�
❑ Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
--E — Certified copy is filed with the gun, buil m ms c- ADDRESStion dep rt�nt NUMBER FIXTURE OR ITEM Q FEE LOCALITY,r.1/ WATER CLOSET
Date _v Applicant NEAREST ^ i
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL
ADDRESS / r�
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TE NO
so as to become subject to the Workers'Compensation Laws DISHWASHER
CONTRACTOR ryl
Datepplicant CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject-to the Workers' CITY �j/� TEL NO 3^��
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM ` '"
with comply with such provisions or this permit shall be STATELIC
deemed revoked WATER HEATER LICENSE NO 33 4' CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO OCE5.SED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,an m lit n is in full fort nd effect 5 PER SYS FINAL
3 DATE VALIDATION
License Num a Lic Class 129
p ^ FINAL
Contractor Lp C /a'��/j�
' ate BY a--�
❑ I am exempt under Sec � W
`/
B &P C for this reason
Plan check fee
Date '
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE 3d
Plan check applicant
SINGLE FAMILY 8 4 J,0 A
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's LicenseAddress { o io o o o 5
Law for the following reason (Section 7031 5, Business and '
Professions Code) City -Tel No 2 0 - 30.50
❑ I, as owner of the property, will do the work and the c c oc
structure is not intended or offered for sale (Section 3 Q`5 Q c'
7044, Business and Professions Code)
0 1.24-84
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 jaws regulating Plumbing, and hereby
authorize re rese tat es of this C unt to enter upon the
ve- one pop y rens e t purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date