HomeMy Public PortalAbout10163 LOWER AZUSA RD_Plumbing__ WORKERS' COMPENSATION DECLARATION 20-0026 APPLICATION/�TION F®p PLUMBING-
PERMIT
.I,hereby;•affirm that'I have a certificate of.consent to self in- 76A667A DPW 4/87 /`1 L� �.rM 1r I< ,Y, �.7 r LR1Y, F�
%t sure or-a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86)
certified copy,thereof (Sec. 3800, Lab. C.)
C .� COUNTY-OF LOS ANGELES DEPT:'OF P.IIBLIC WORKS'
Policy No,. =L=-Company.
`Certified copy-is hereby furnished.
FOR APPLICANT TO FILL IM(PRINT OR TYPE) ' BUILDING
Cw4ified copy.is filed with the ty building insp tion ADDRESS 6 (/
epariment. NUMBER FIXTURE OR.ITEMM @ FEE LOCALITY
WATER CLOSET(TOILET)
Daie"° Applica NEAREST
BATHTUB CROSS ST.
CERTIFICATE OF EXE TI FROM WORKERS' Z (U'�/
COMPENSAT INSURANCE OWNER '
SHOWERO
(This,section need not be completed if the work involved by D ' MAIL
the permit is for one hundred dollars ($100)or less.)- LAVATORY ADDRESS' `' AW
I certify that in the,performance of the work for which this per- SINK
mit is issued, I shall not employ any'person in any manner so 'l - CITY .8,e.,- TEL. NO,.
as to become subject to the Workers'Compensation Lows. DISHWASHER
/��I, CONTRACTOR G �S J
Date —Applicant, CLOTHES-WASHER (f " ADDRESS
NOTICE TO APPLICANT: If, after'making'this Certificate of Ex- SWIMMING POOL RECEPTOR
should you should become subject to the Workers'Compen- CITY TEL. NO. 3
sation;provisions of the Labor Code,,you must forthwith comp- LAWN.SPRINKLER SYSTEM.
ly with such provisions:ar this permit.,sh'all be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. Sl L CLASS G
LICENSED CONTRACTORS DECLARATION DISTRIO. OCESSED BY
I hereby affirm that I am I'icensed uncler provisions of Chapter GAS SYSTEM OUTLETS (Q/
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
fed Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINA VA DATION
DATE ' O
License Num er V Lic. Class G �
ETNA U
Contrac � ate ` 'C .:d� BY % o
1 am exempt•;under Sec JrW
CL
B.&P.0 for this reason ► 9 0 9 Q,6 A V)
Plan.check fee
Date: PLUMBING PERMIT ISSUING FEE$ Q # ° ° ° ° ° 5
Signature TOTAL FEE <I ° ° 9 4 5 d
SINGLE FAMILY Plan check opplicant .
HOME OWNER-BUILDER DECLARATION" '
I hereby affirm that I am exempt from the Contractor's License Name °°o'.9U.505
Law for the following reason (Section 7031.5,. Business and
Professions Code): Address ( Q1 9 8 8
I, as owner of the property, will do the work and the City Tel. 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 I have read this applicafion and state that the
above information is correct. I agree to comply.with a,ll County ,
pinancd State laws regulating Plumbing, and hereby
es rives of his County to enter upon the
ed-proppurposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ermittee Date