HomeMy Public PortalAbout10159 LOWER AZUSA RD_Plumbing__ :WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING. PERMIT
I'here'by,joffi'fin-that I•hove a certificate of consent to self in- 76A667A PW a/87
sire be a czrtlficate of Workers'Compensation Insurpnc ,or a CE 817'(REV. 8/86)
certified.copy thereof (Sec. 3800, Lab. ) = O.
Policy No
J�— 'lo7Company ECJ j ` . COUNTY. OF LOS ANGELES DEPT.,`OF'PUBLIC-WORKS
Certified copy is hereby furnished.
£FOR APPLICANT TO FILF•IN (PRINT OR TYPE) BUILDING
2>-�ertified copy is filed with the county building inspection -ADDRESS zeaezJ09-
department.
¢department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY -
/G-ZI WATER CLOSET(TOILET),
Dare '•C �� V App i D NEAREST
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CERTIFICATE OF EXEM I FROM WORKERS_'
BATH`TUB V CROSS ST. k.
COMPENSATI INSURANCE SHOWER G!�l OWNER
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(This section need not be completed �f the work involved by ) MAIL �yiy' .' �
the permit is for one hundred dollars.-($100)or less.) LAVATORY U ADDRESS �o Z
I certify that in the performance of the work for which this per 1 J1
mit is issued, I shall not employany perSINK son in any manner so � (/ (� CITY TEL. NO.
as to become subject to the'.Workers''Coin pensat ionLaws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ✓ ADDRESS t~L�
NOTICE.TO APPLICANT: If, after making this Certificate of Ez- LC��O G
SWIMMING POOL RECEPTOR / 4� 33
emption;you should become subject to the Workers'Compen- - _ CITY / yi�+7�/����¢ TEL. NO.
sation provisions of the Labor Code,you must forthwith-comp- LAWN SPRINKLER SYSTEM
"ly with such provisions or this permit shall be deemed revok- STATE ��q L LIC:
ed. WATER HEATER LICENSE NO. ( CLASS
LICENSED CONTRACTORS,DECLARATION d� DISTRICT NO. PROCESSEDF4 B -
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM 1 OUTLETS i1
9(commencing'with:Section 7000)of Division 3 of-the Business OUTLETS OVER (/
and Professions Code, and my license is in-foil force and ef- 5 PER SYSTEM FINAL VA ATION.
fect..
O
License Number Cic. Class DATE
U
F I NA cc
Contra r [ y�Date L a~/ �O BY O
t'-
El I
am exempt under'Sec. LU
B.BP.C. for this reason
Plan-check fee F ►
Date: PLUMBING PERMIT ISSUING FEE$
,Signature
TOTAL FEE G S z 095 2 A
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant # o o oto 0 5
Ihereby affirm that I am exempt from the Contractor's License Name ( 0 0 94,5 0
Law for the following reason (Section 7031.5, Business and
Professions Code): Address 0 0 0 9[I 5 0
I;as-owner of the property, will do the work and the City. Tel. No.
structure isnot intended or offered for sale(Section 7044; ) 0, 1 9 8
Business-and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction'lending agency for
the perftrmonce'.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,informatjon 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
ention d roperty.for inspection purposes.
`� � SEE REVERSE FOR.EXPLANATORY LANGUAGE
ature of Permittee Date