HomeMy Public PortalAbout9132 LONGDEN AVE_Plumbing__ f
WORKERS'COMPENSATION DECLARATION. APP1ln�CAMN FOR PLUMBING G l�ERjnn�� T
I^Inereby.16frirm that I have a certificate of consent to self 76A667A
insure, of a certificate of Workers' Compensation Insurance, CE 817(REV 10/81) � •
orracecertified copy thereof,(Sec 3800,'Lob C ) COUNTY OF LOS ANGELES BUILDING AND"SAFETY
Poli No 61 CompanynY�fl
Certified copy is hereby furnished
F-1FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS
tion department NUMBER FIXTURE OR ITEM @ FEE LOCALITY
S-7--&b WATER CLOSET i
Date Applicant NEAREST ,. � •
CERTIFICATE OF EXEMPTION'FROM WORKERS' BATH TUB CROSS 5T i
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work Involved by SHOWER
the permit is for one hundred dollbrs ($100)or less.) LAVATORY MAIL
ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL NO
so as to become subject to the Workers'Compensation Laws DISHWASHER
CONTRALTOR_rk(III
N S
Date Applicant CLOTHES WASHER ADDRESS
NOTICE
NOTICE TO APPLICANT If, after making this Certificate of eg
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTORf
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY ei g, TEL NO
with comply with such provisions or this permit shall be STATEG (/ LIC
deemed revoked WATER HEATER LICENSE NO 3&' /�a CLASS
LICENSED CONTRACTORS DECLARATION DISTRIC0 - PR?7 BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM T ""6UTLETS Q c
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER .and Professions Code,and my license is in full force and effect 5 PER SYSTEM FINAL
DATE �� 1 VALIDA W
License Number -3�? 15k Lic Class
r t FI U
Contractor ��l dlJ Date 3-74 k 01
❑ I am exempt under,Sec 0
U
B 8P C for this reason W
Plan check fee ' N
Signature I
Date PLUMBING PERMIT ISSUING FEE$ .a Z
-
TOTAL FEE 21-
;24194A
Plan check.applicant
SINGLE FAMILY
o'0 0 0 0 5
HOME OWNER-BUILDER DECLARATION Name #
I hereby affirm that I am exempt from the Contractor's License Address t) ° ° 2 5
Law for the following reason (Section 7031 5, Business and
Professions Code) City Tel No - o o o 2 a 5 0 v `
❑ I, as owner of the property, will do the work and the
structure is not •intended or offered for sale (Section 0 3'1 $6
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 jaws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned ra erty for inspection purposes
• SEE REVERSE FOR'EXPLANATORY LANGUAGE
(Xignature of Permittee Date
I