HomeMy Public PortalAbout9449 LAS TUNAS DR_Plumbing__ WORKERS'COMPENSATION DECLARATION6 DPW a/87
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APPLICATION FOR PLUMBING PERMIT
I hereby-affirm that I have a certificate of consent to self in- 76A666A667A
sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86)
certified copy thereof (Sec. 3800,.Lab C.)
Policy No. CCOUNTY OF LOS ANGELES DEPT.•OF PUBLIC WORKS
ompany .
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING CAA-)
'
F1 Certified copy is filed with the county building inspection ADDRESS
NUMBER FIXTURE OR ITEM LOCALITY
department.: @ FEE
WATER CLOSET(TOILET)
Date Applicant - NEAREST,
CERTIFICATE OF EXEMPTION FROM WORKERS', BATH TUB CROSS ST.',
COMPENSATION INSURANCE OWNER' c
SHOWER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) -LAVATORY i' - ADDRESS , TkL4
I certify that'in the performance of.the work for.whick this per-
mit-is issued, 1 shall not employ any person-in any manner so SINK _ "CITY _ TEL. NO. -
as to become subject to the Workers' Compensation Laws. DISHWASHER
CONTRACTOR
Date ✓�'� !Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If; after making this Certificate ofEz- SWIMMING POOL RECEPTOR
Z
erription,you should become subject to the Workers'Compeh- CITYTEL. NO.
sation provisions of the Labor Code; you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or•.this•permit.shall be deemed revok- STATE LIC
ed:. . %: . WATER HEATER LICENSE NO. 41� 11� CLASS 10
LICENSED CONTRACTORS DECLARATION DISTRICT NO. O SSED BY
1 hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM. OUTLETS �� G
9(commencing with'Section 7000)of Division-3 of the Business OUTLETS OVER- d
fed Professions-Code, and my license is in full force'and ef- 5 PER SYSTEM FINAL VALIDATION a
yQ DATE 7 U
License Number Lic. Class twig;
FINA
Contractor's L ` Date 3_" 10 -0 1 BY 0
I-am.exempt under Sec. - W
1 .. LU
B.&P.C. for this reasonPoo. 2
Plan check fee
Date: 'S--� Q �`"1, PLUMBING PERMIT ISSUING FEE$
Signature a,�.5 S�
TOTAL FEE O
SINGLE FAMILY
HOME OWNER-BUILDER bECLARATION Plan check applicant:
I hereby,affirm that I am exempt from the Contractor's License Name'
Law for the•following reason (Section 9031.5, Business and
Professions Code): Address
I, as owner bf-the property; will dothework and the City Tel. No.
structure is not intended or offered for sale(Section 7044, -- ='s
Business and Professions Code).
10111.
CONSTRUCTION LENDING AGENCY
I hereby:affirm that:there,is a construction lending agency for- �. r
the performance of the work for which this permit is issued- ;,:z•2:
(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.,)agree to comply with.all CountyPoo. i •J ''-(j
ordinances and State laws regulating Plumbing, and hereby "
'authorize representatives of this County,to enter upon the
above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
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