HomeMy Public PortalAbout9628 LONGDEN AVE_Plumbing__ f.WORKERS'COMPENSATION DECLARATION 20-0026 DPW 4/87
APPLICATION FOR PLUMBING PERMIT
V, lie, r�t offirr`n that I have q certificoLp of consent to self in- 76A667A 1
JJL I,a cert ncate of'Norkers'Compensation Insurance,or a CE 817(REV. 8/86)
certit. ;cspthereof
((Sec. 3800, Lab. C. Ir
Company � COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No.,#YAM
Certified eopy is hereby furnished.
� FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM ADDRESS
d artment. @ FEE
LOCALITY C!
Date Applicant 1)e WATER CLOSET(TOILET) r �� NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER / / OWNER
(This section need not be completed if the work involved by �J G/' MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY U0 ADDRESS 17
I certify that in the performance of the work for which this per- SINK CITY TEL NO C�
mit is issued, I shall not employ any person in any manner so QC 7
WIT
as to become subject to the Workers'Cornpep3ation Laws. DISHWASHER
/� CONTRACTOR WVep
Date Applicant O CLOTHES WASHER 6 VADDRESS
NOTICE TO APPLICANT: If, after ma ing this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY TEL. NO 7—
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE �� D LIC.
ed. WATER HEATER l'r J1 LICENSE NO. 2- CLASS
LICENSED CONTRACTORS DECLARATION (�/ DISTRI�. ROCESS BY
1 hereby affirm that I am licensed under provisions of Chapter GAS SYSjEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
t
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL ALIDATION 9'
fect. 9—/
�— , DATE V .� a'
License Number /82��2- Lic. Class� 0
FIN IIZ
Contractor Date BY O
❑ I am exempt under Sec. W
d
B.&P.C. for this reason g
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ ;9 0 4 34 A
Signature TOTAL FEE qy # 0 0 0 0 0 5
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant o 0 9 Q.5 0
1 hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and o 0 0 9 JL 5 C
Professions Code): Address
Cit Tel. No. 0816-88
I, as owner of the property, will do the work and the Y
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 tIPI
ply with all County
ordinances and State laws regulatibing, and hereby
authorize represent es i Coto enter upon the
a t' ed p per.. f e n purposes.
�b SEE REVERSE FOR EXPLANATORY LANGUAGE
grgnb 010f Permittee Dafy