HomeMy Public PortalAbout9501 LEMON AVE_Plumbing__ PW
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
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 Q / /�Af '
Certified copy is filed with the county building inspec- ADDRESS J
tion department NUMBER FIXTURE OR ITEM Q FEE' LOCALITY
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by MAIL t+ /
the permit is for one hundred dollars (;100)orless.) LAVATORY ADDRESS .J e
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'Comp nsati Laws DISHWASHER j� �
� CONTRACTOR c ,
Date Applicant CLOTHES WASHER ()
NOTICE TO APPLICANT If, after making this Certificate of ADDRESS .�� ofR
,
Exemption, you should become sublect to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth,- LAWN SPRINKLER SYSTEM CITY fes, d GA T O �S7- �jG®
with comply with such provisions or this permit shall be STATE !`✓ /T ] LIC 0/
deemed revoked, WATER HEATER LICENSE NO44� of CLASS
LICENSED CONTRACTORS DECLARATIONDISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS D�
(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
DATE VALIDATION V
License Number 7- /�<���J Lic Class A v `r�`�V� `' J U
�� G r/ r FIN
,o O '
Contractor ` Date BY V
❑ 1 am exempt under Sec IL
B&P C for this reason Z
• Plan check fee _
Date
Signature
PLUMBING PERMIT ISSUING FEE$,
,
g TOTAL FEE -T37a7A
Plan check applicant 2 G C a 5 V
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name o 0 0 `Z 2 5 O
'I hereby affirm that I am exempt'from the Contractor's License 50
gddress
Law for the following reason (Section 7031 5, Business•and
Professions Code) Cit Tel No GA 0 9-8,6-
1,
❑ v
I, as owner of the property, will do the work and the ,
structure is not intended or offered for sale (Section'
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 ,
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
abov enti d ro erty for inspection purposes
SEE REVERSE FOR.EXPLANATORY LANGUAGE
Signature of Permittee Date