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HomeMy Public PortalAbout9861 LONGDEN AVE_Plumbing__ J . WC 'KERS' MPESNSATION DECLARATION .,. P 20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT I her a r�shattl Mabe a certificate of consent to self in- 76A667A sure,orla Eertificate of Workers'Compensation Insurance,or a CE 817(REV 8/86) certified co thereof (Sec. 3800, Lab. C.) LI %� 0 COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy Company, Certified copy:s hew-by furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING / D� �n CdIrtified copy is filed with the count building inspectio ADDRESS 67 1 depar ent NU BER FIXTURE OR ITEM @ FEE LOCALITY / !� Date l qp va� WATER CLOSET(TOILET) NEAREST ` /©© CERTIFICATE OF EXEMPTION FROM WORKE 2j BATH TUB �61JROSS 5T, iZe-7�COMPENSATION INSURANCE SHOWER WNER /�- 77'77 (This section need not be completed if the work involved by C• �J, the permit is for one hundred dollars($100)or less.) LAVATORY L) ADDRESS /�� I certify that in the performance of the work for which this per- / SINK O v CITY TEL NO mit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. DISHWASHER 14/ /F� Z� CONTRACTOR [� `/- Date Applicant CLOTHES WASHER v v ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR empfion,you should become subject to the Workers'Compen- CITY �'J,/�y h TEL NO. _W7 sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE y// � LIC ed. WATER HEATER Q LICENSE NO 6 f7 CLASS LICENSED CONTRACTORS DECLARATIONDIST Ng:,, �RROCES D BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM f OUTLETS ,Led- 9 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 1 5 PER SYSTEM FIN ��� Lo� IDATION a fect. L` 0 /'�/ (� �j DAT O License Numb/er "Date Lic. Class frl ` O U QContractor (� O H I am exempt under Sec. W B.BP.C. for this reason ® W Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE 2 01 3.7 A SINGLE FAMILY k h Plan check HOME OWNER-BUILDER DECLARATION Papplicant # o o 0 0 0 5 I hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and - 8250 Professions Code): Address x ❑ I, as owner of the property, will do the work and the City Tel. No. o o o 8 2 5 06 structure is not intended or offered for sale(Section 7044, Business and Professions Code). ® 07 1 2 —8 8 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 ordinancZan d Stte laws regulating PI tubing, and hereby authorizeresentatives o this Cou to enter upon the abov - (2)1e sgj/r o / SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date