HomeMy Public PortalAbout9531 LONGDEN AVE_Plumbing__ %VORKERS.COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
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I heroy•a'ffirmFthat I,have a certificate of consent.to self '20-0026a 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 ,
Ce011fied copy is hereby furnished. ,
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING _
Certified copy is filed with the county building inspec- ADDRESS Lo iss i,r2 ✓—
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
WATER CLOSET
Date Applicant CROSS ST.
.CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB
COMPENSATION INSURANCE SHOWER p•y OWNER
(This section need not be completed If the work Involved by vv
the permit is for one hundred dollars($100)or less.) i LAVATORY DDRESS rj cr A
1 certify that in the performance of the work for which this
permit is issued,I shall not employ an person in an manner SINK CITY ` TEL.NO.
P P Y Y P Y I E �' fo.6
so as to become subject to the Workers'Compensation LOWS. .I DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' I CITY TEL.NO.
Compensation provisions of.the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such -provisions,or this permit shall be ' STATELt .
deemed revoked. WATER HEATER LICENSE NO. Cass
LICENSED CONTRACTORS DECLARATION DISTRICT NO. P OCE BY
I hereby affirm-that I am licensed under provisions of Chapter 9, GAS SYSTEM OUTLETS G
(commencing with-Section 7000)of Division 3.of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL ALIDATION d
DATE C
License Number_ Lic.. Class C;
Contractor Date BY C
❑ I am exempt.under Sec. t.
B.$P.C. for this reason LL
y LL
Plan.check fee ® rf
Date: PLUMBING PERMIT ISSUING FEE$
Signature 13 10
TOTAL FEE
SINGLE FAMILY Plan check applicant
HOMEOWNER,—BUILDER.DECLARATION Name A Tons
I hereby affirm that.I am exempt from the Contractor's License ;
Law for the following reason (Section 7031.5; Business and Address 3307 35.511
Professions Code): ! City Tel. No.
1 ITEMS,
I, as owner of the property, will do the work and the TOTAL ,
structure is not intended or offered for sale (Section)
35.511)
7044, Business and Professions Code). i
_ CHECK 35a50
CONSTRUCTION LENDING AGENCY CHANGE oaf
I hereby affirm that there is a construction lending agency fors
the performance of the work for which this permit is issued.
(Sec. 3097,Civ. C'.).
0000-0001 5/22/90.
Lender's Name 08.35 1 AM 9:06
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 pop
ordinances a State laws regulating Plumbing, and hereby
authorize resentatives o h1s County to enter upon the
above- ntioned'prope inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE "
P s -art -1�0
igncture Permitte Date