HomeMy Public PortalAbout9652 1/2 LIVE OAK AVE_Plumbing__ ' WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
P hereby,affirm that I have a certificate of consent to self 76A667A
insure, or a certificate of Workers'.Compensation Insurance, CE 817(REV.8/86)
or a certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF.PUBLIC WORKS. ,
ajcy No. Company
Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING /� s^7 / / ^P / ,
Certified copy is filed with the county building inspec- ADDRESS %� 6 � L»!1! <=: (J/� (�(f/
tion department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY
-Rmk C 161 C ,417,bD
WATER CLOSET 4 Q '/
Date Applicant NEAREST I C
CERTIFICATE OF EXEMPTION FROM WORKERS' l BATH TUB G► CROSS ST. A�'IIC,-
COMPENSATION INSURANCE SHOWER OWNER ' 6
(This section need not be completed if the work involved by {1 MAIL n `
the permit is for one hundred dollars($100)or less.) j. LAVATORY '� �U ADDRESS (/ (L� l�[
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY A&C�qp l TEL. NO.3
so as to become subject to the Workers'Compensation Laws. DISHWASHER
�` r �/7 !(nwA' CONTRACTOR
Date 4f-G6_d Applicant' `' ` CLOTHES WASHER
of ADDRESS
NOTICE TO APPLICANT: If, after making his Certifica
Exemption, you should become subject to the War ers SWIMMING POOL RECEPTOR
CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
V DATION
License Number Lic. Class DATE .22 7 7 IL 3 A
�,
N
Contractor Date B # o-o o a o 5
❑ 1 am exempt under Sec, 'I ° ° 46150 �
B.BP.C. for this reason (� 5 =
Plan check fee ® ° °'° 05
Date:
PLUMBING PERMIT ISSUING FEE$ 08,25-87
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address
Law for.the following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
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
Poo-
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned roperty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
7
Signature of Permittee Date