HomeMy Public PortalAbout9648 LONGDEN AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
!4hefeiiy of#iri'„n thafod F ave a certificate of`consent to self 76A667A
ws'r'ns'ure,�o� a certificate of Workers'-Compensation Insurance, CE 817(REV. 10/81)
ieerr pc rtitied copy thereof(Sec. 3800, Lob. C.) c COUNTY OF LOS ANGELES. BUILDING AND SAFETY
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Cpany F ek!l __.n_S �1� .
Certified copy is hereby furnished. BUILDING F
FOR APPLICANT TO FILL'IN:(PRINT OR'TYPE) ADDRESS �q Q
Certified copy is'filed with the county building inspect A C�
NUMBER FIXTURE OR LOCALITY
tion department. �+ �� FEE
Date °-�8W Appligant e fY t.4P O.P Y tl WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS.' BATH TUB CROS
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER C_
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the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this
U G1. r n. �e,
permit is issued, I shall not employ any person in any manner SINK At—)
CITY a TEL.NO. S,O
so as to become subject to the Workers'Compensation Laws. DISHWASHER
a CONTRACTORclnaflejq- 0�0 CQ C
Date Applicant CLOTHES WASHER v .ADDRESSAV
NOTICE, TO APPLICANT: If., after making this Certificate of
Exemption, you should become subject to fh..e 'Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Lobar Code, you must forth- CITY TEL.NO.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this.permit shall be STATELIC.
deemed revoked. WATER HEATER LICENSE NO. L4 9 CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ESSED B
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS o
(commencing with Section 7000)of-Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
(� DATE VALID ION
License Number Lid. Class.
fir, FIN
Contractor Date �' T By
Ul
I am exempt under Sec.
BA PX. for this reason7J O 8 [( A
Plan check fee
D. @' # 0 0 0 0 6 5
PLUMBING PERMIT ISSUING FEE-$.
Signature
TOTAL FEE I o 1 7$5 O
SINGLE FAMILY Plan checkPP oa17&50
a licant 178,5053
HOME OWNER-BUILDER DECLARATION Name I G07-85
I hereby affirm that I am exempt from the Contractor's License Add
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 said (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
_/Q/L�
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
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to .enter upon the
above-ment' ned operty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signal of erm.ittee Date