HomeMy Public PortalAbout9548 LIVE OAK AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT ��77
14�ereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a 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 e
Certified copy is filed with the county building inspec- ADDRESS u
tion department. 'NUMBER FIXTURE OR ITEM @ FEE
LOCALITY o
WATER CLOSET
Date Applicant NEAREST o
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. ( S�
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this 1,
permit is issued, I shall not employ any person in any manner SINK CITY TO NO. It
n
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- CITY TEL. NO.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be
STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS o�
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
'_�ZLicense Number Lic. Class DATE �
FINAL
Contractor Date BY
❑ I am exempt under Sec. ®/
B.&P.C. for this reason
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature /
TOTAL FEE bo
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License -.„•;•- s
Law for the following reason (Section 7031.5, Business and Address
ess : City Tel. No.
i�:_•_•::,�
Professions Code)
ElI, 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). ® -T A3 -g
CONSTRUCTION LENDING AGENCY f•„t=t,,'•. i j: BEY
I hereby affirm that there is a construction lending agency for -
the performance of the work for which this permit is issued ;•yA, 1” r;^:
(Sec. 3097, Civ. C.). -
Lender's Name
Lender's Address
I certify that I have read this application and state that the ® L: __
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize repres ives of this County to enter upon the
bo a men coned ro erty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date