HomeMy Public PortalAbout9650 LONGDEN AVE_Plumbing__ ��.TT' �TRI<F1RS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
The'reb'y afirYn that I. have o certificate of consent to self. 76A667A
insuretor a c6rtihcate of Workers;r•Compensation insurance, CE.1.17(REV. 10/81) e;
�> '...or aertl�f��ie��d��c,+o+�py thereof(sec.3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
.❑o icygo�`. ��� Company FLd`�NY>G7vt�
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING -
Certified co is filed•with the count buildin pec- ADDRESS
copy y . gins NUMBER FIXTURE OR ITEM @ FEE 4
tion department. LOCALITY 1
Dote — Applicant WATER CLOSET 610 NEAREST .
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS.ST. 1
COMPENSATION'INSURANCE OWNER L
(This section need not be eo'mpleted If.thework involved by SHOWER
the 49140 MAIL permit is for one hundred dollars(5700)or less.) LAVATORY ADDRESSqq 'd/i/Ir1
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 =,• TEL.NO`T� .
so as to become subject to the Workers'Compensation Laws. DISHWASHER Z
CONTRACTOR
Date Applicant CLOTHES WASHER -11fo ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
Exem .tion., ou should become sub'ect to the Workers" SWIMMING POOL RECEPTOR '
P Y 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 STATELIC.
deemed.revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NQ. . P Et OX SSED B
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ,C�
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER LJ
and Professions Code,and my license is in full force and effect. 5 PER'SYSTENI FINAL VALID TION O
DAT — � U
License Number �' Lic. Class' I9
FIN
ContractorDate Baa
I am exempt under Sec.. �
t»
B:BP.C. for this reason ►
' ,Plan check fee f�
e; V
PLUMBING PERMIT ISSUING FEE.$
Signature
TOTAL FEE .3 0 a 7 A
Plan check applicant
SINGLE FAMILY # o 0 o 0 0 5
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address ( o 1 7&5 0
Law for the following reason (Section 7031.5, Business and
Professions Code)- C:Ity Tel. No. 0 0 1,713,5 0_5
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section , ( a 0- —85
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
1 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 ►
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-menti ned roperty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature ermi tee Date