HomeMy Public PortalAbout9507 LONGDEN AVE_Plumbing__ ,WO)� ERS'COMP)ENSATION DECLARATION rswsara
I he'teby m.that I hAve a certificate of consent to self CE 617;2-60) APPLICATION FOR PLUMBING PERMIT
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icspre,or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
COUNTY OF LOS ANGELES BUIL•DING'AND SAFETY.,
Policy No. Company
0 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS �5_ �o
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE
department. /� LOCALITY
Date Applicant WATER CLOSET V NEAREST
BATH TUB CROSS ST �-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER dQ OWNERS
``'' MAIL c1 y.
(This section need not be completed if the work involved LAVATORY V� AL3DRESS p a
by the permit is for one hundred dollars ($100) or less.) SINK 6 •. i O
t/�f� CITY.. _TEL.•NO. 3 U
I certify that in the performance of the work for which this DISHWASHER U� ONTRACTO
permit is Issued, I shall not employ any person in any manner 6 (dp,E O
so as to become subject to the rs' ensaY kA Laws. CLOTHES WASHER ADDRESS (~j
Date Applicant SWIMMING POOL RECEPTOR W
NOTICE TO APPLICANT: If, of r making this Certificate of CIT "Al 6TEL. N
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STAT - LIC.
Compensation provisions of the Labor Code,you must forth- WATER HEATER LICENSE NO. a�3 CLASS 6 c/
with comply with such provisions or this permit shall be
deemed revoked. GAS SYSTEM 6- OUTLETS Qv DISTRICT
//��NO. PROCESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER ✓.. U�
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL v
ness and Professions Code, and my license is in full force and DATE VA ATION
effect.
License Number 516527.3 Lic.Class L-`'3� FIN
BY
Contractoa9316uAS /d-.2 "3
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE 33 Q 9 A
Lic,or Reg.No. Date Plan check applicant # 0,0 0 0 0 5
HOME OWNER-BUILDER DECLARATION Name i 0 o 9 4 5 0
I hereby affirm that I am exempt from the Contractor's Address o 0 o 9 4.5 0 5
License Law for the following reason (Section 7031.5, Busi- City Tel.No.
ness and Professions Code):
� '•I 0,28-85
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project
(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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned pro erty for inspection purposes.
G-a-?-PJ
SigmMure of Permittee Date