HomeMy Public PortalAbout9528 LIVE OAK AVE_Plumbing__ i
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �7
1 he,rebyXff.irm tkat I have a certificate of consent to self 20-0026 DPW 6/87
14ure, or certificate of Workers' Compensation Insurance, 76A667A
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN PRINT OR TYPE BUILDING
Certified copy is filed with the county building inspec-
I ADDRESS `� 'L1 v� �"/� /C' Gf
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant / WATER CLOSET .�� NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' ` BATH TUB C v CROSS ST. / c ( -1 '�y�/�/L�.
COMPENSATION INSURANCE SHO WEROWNER
(This section need not be completed if the work Involved by p
the permit is for one hundred dollars ($100)or less.) / LAVATORY V v MAIL ADDRESS S � as ahe1,e
I certify that in the performance of the work for which this ��G
permit is issued, I shall not employ any person in any manner / SINK �� CITY Til - TEL. NO.
so as to become subject to the Workers'Compensation Laws. / DISHWASHERC
CONTRACTOR /�
Date Applicant CLOTHES WASHER ADDRESS 9�as L1 F/� � /j re„ e
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR /�
CITY TEL. NO. Q �3
Compensation provisions of the Labor Code, you must forth-
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be ��JSTATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION OJT DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (J
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER !/
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL u VALIDATION
�o
DATEr z,�1�..+��i ®.
License Number Lic. Class 0,,
FINAL
Contractor Date BY ®'
❑ I am exempt under Sec.
Lsd
fes'
B.&P.C. for this reason Plan check fee oil. U)
Date: PLUMBING PERMIT ISSUING FEE$ /�
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address -,n-. i"
Law for the following reason (Section 7031.5, Business and _
Pr fess ions Code): City Tel. No. ___ �i";
`
sU"t, as owner of the property, will do the work and the
L structure is not intended or offered fo •ar sale (Section „
7044, Business and Professions Code). ® I
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for -"
the performance of the work for which this permit is issued G f„
(Sec. 3097, Civ. C.).
Lender's Name ,,T- 'n
.L
—:1 J.
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
above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnotur of Permittee Date