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HomeMy Public PortalAbout10161 LOWER AZUSA RD_Plumbing__ 'r WORKERS' COMPENSATION DECLARATION APPLICATION FOR. PLUMBING PERMIT I hereb ­a firm that f.have a certificate;of self i76A667A consent to n- 20-0026 DPW a%87 n y�, f '. 'dull :,'sure„ora certificate of Workers'Compensation Insurance,ora CE 817(REV. 8/86) certified copy thereof (Sec. 3800, Lab. )' Policy No. T�; / ' Company j '” COUNTY OF LOS ANGELES DEPT. OF'PUBLI,C WORKS .` ' Cer copy is hereby furnished.' FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed wit t building inspection ADDRESS department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY �yy= �2• L6_/FWATER:CLOSET(TOILET) _ D� Date, Appl ica NEAREST CERTIFICATE OF EXE TIO ROM WORKERS' Z BATH,TUB. CROSS STs * .. COMPENSA NSURANCESHOWER �, OWNER ' •. �C-.�' 7�' •J�� - (This section need.not be completed if the work involved by MAIL *; the permit is for one hundred dollors'(;100)or less:) LAVATORY-!iyy ' ADDRESS Z " r I'certify thot in the performance of the'work for which This per- J C7 mit is issued, I shall not employ any person in any manner so SINK DCITY TEL NO. as to become subject to the Workers'Compensation Laws. - DISHWASHER CONTRACTOR Date' Applicant CLOTHES WASHER © Li^ NOTICE TO APPLICAN_T.:'If, after making this Certificate ofAEx- SWIMMING POOL RECEPTOR' ADDRESS emption,you should become subject to the Workers'Compen- CITY TEL. NO.'FZ 33 sation provisions of the Labor Code,,you must forthwith comp- LAWN SPRINKLER SYSTEM Iy with such provisions.or this permit shall be deemed revok- STATE L C UC C.� ed. WATER HEATER i(� LICENSE NO.,67 T CLASS LICENSED CONTRACTORS.DECLARATION (O DISTRICT .. PROLES BY I'hereby,offirm that 1 am licensed under provisions of Chapter l GAS SYSTEM OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS,OVER and Professions Code,man/d mylicenseis in full force and ef- 5 PER SYSTEM FINAL ✓�� V LIDATION f . : �7L / C DATE O License Number Lic. Class O 2 FINAL Contract r. ate BY O I am exempt under Sec. I W B.&P;C: for this reason pop. 9 4 7 A g Plan check fee ' Date: PLUMBING PERMIT ISSUING FEE $ # o 6 ro 0 0 5 Signature TOTAL FEE ( o - 94,50 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant x I hereby affirm that I am exempt from the Contractor's License Name 0 0 094,5 0 2 Law for the following reason (Section 7031.5, Business and Professions Code): ' Address ( 1a.8 0 9 FJ 1, as owner of-the property, will do the work and the CityTel. No. structure is not 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 h have read this application and state that the poll.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 ,q a)e-menti d roperty for inspection purposes. �I SEE REVERSE FOR EXPLANATORY LANGUAGE ignature o Permittee Date