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HomeMy Public PortalAbout10155 LOWER AZUSA RD_Plumbing__ .REPS'COMPENSATION DECLARATFON20-0026 APPLICATION FOR PLUMBING PERMIT I fiEreby,vffi,hij'that I hav'e.a certificate of consent to self in 76A667A PW 4/87 sure;;or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) certified copy thereof (Sec. 3800,,Lab.,-C.) /- - ZI^77-67Com an EW �iSNJeE COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS T Policy No. p y - Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN (PRINT OR TYPE) ADDRESS Certified copy is filed with the co building inspection department. NUMBER FIXTURE OR ITEM Co FEE LOCALITY Date l©�!^1FtApplicant ., 3', WATER CLOSET,(TOILET) �/(/ NEAREST . BATH TUB /� CROSS ST. CERTIFICATE OF EXEMPTI ROM WORKERS' � VD' COMPENSATION SURANCE SHOWER ,b OWNER (This-section need not be completed if the work involved by ALJ MAIL I' I the permit is for one hundred dollars ($100)or less.) 3 LAVATORY ADDRESS 2-6M 2 &LC I certify that in the performance of the work for.which•this per- SINK (� CITY TEL. NO. mit is issued, I shall not employ any person in any manner so g� as to become subject to the Workers'Compensation,Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS z W r �r`11r70Q NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR p emption,you should become subject to the Workers'Compen- CITY OQ TE . ! sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM Qr— ly with such provisions or this permit shall be deemed revok- STATE 7 G `/ UC. / ed. / WATER HEATER /(/1 LICENSE NO. �L d CLASS 3 ip LICENSED CONTRACTORS DECLARATION t�v GAS SYSTEM OUTLETS DISTRICT NO. PROCESSED BY I hereby-affirm that 1 am licensed under provisions of Chaptef / v 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER (moo -and Professions Code; and my license is in full force and ef- 5 PER SYSTEM FINAL _ VALID ON fect. DATE !iicense Number Sal!1.49Lic. Class 0 T,. V �EA)f tl U �LC�d JLcH Q FIN 0 Coniracto ate BY p I am exempt under Sec. UJI B.&P.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ U ► 2209 4,8 A Signature # o 0-o 0 0 5 TOTAL FEE SINGLE FAMILYPlan check applicant I 9 ° 94,50 HOME OWNER-BUILDER DECLARATION _ I hereby affirm that Lam exempt from the Contractor's License Name 0 0 0 9(I,5.0 v Law for the following reason '(Section'7031.5, Business and Professions Code): Address IQ1988 I, as owner'of the property, will do the work and the City Tel. No. structure isnot 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 to comply with all County , ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the qbcvV-menti operty for inspection purposes. �0�/9_ SEE REVERSE FOR EXPLANATORY LANGUAGE Sinature of Permi ee Date