HomeMy Public PortalAbout10165 LOWER AZUSA RD_Plumbing__ WORKERS' COMPENSATION DECLARATION
20-0026 DPW 4/87 ,APPLICATION FOR PLUMBING PERMIT -
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I hekeby, affirm That I have a certificate of-consent to self in- 76A667A.
sure„or a certificate of Workers'Compensation insurance,or a CE 817(REV. 8/86)
certified copy thereof (Sec. 3800,Lob.,C. y
Pcy NooinpanY COUNTY OF LOS ANGELES DEPT. OF"PUBLIC WORKS,
oli .77��-L� ��
�. Certified copy is hereby furnished
FOR APPLICANT TO FILL IN'(PRINT OR TYPE) BUILDING
�ertified copy is filed with the c unty building inspection ADDRESS �Z(G
department. NUMBER FIXTURE OR,ITEM @ FEE/�J) OC
ALITY
Date` ` . �k A_ppli an WATER CLOSET(TOILET). Vo NEAREST
BATH TUB `t CROSS'ST.
'CERTIF.ICATE OF EXEMP I FROM WORKERS'. USI
COMPENSATI INSURANCE OWNER
SHOWER
(This section need riot be completed if the work involved by !� MAIL
the,permit is'for""one hundred dollars"($100)or-less.) LAVATORY \v: ADDRESS �� � '
I certify that in the'performance of the workfor.which this per-
SINK r
mit is issued, I shall not.employ any person.in any manner so. CITY �✓J TEL NO.
ps to,become subject to the'Workers' Compensation Laws. ,G
.DISHWASHER CONTRACTOR
Date Applicant CLOTHES WASHER _ � (Nr ` `�•Jc
NOTICE TO APPLICANT:.If, after making this Certificate'of Ex- ADDRESS
tion,you should become subject to.the Workers'Com en- SWIMMING POOL RECEPTOR
em
P Y I P CITY TEL. NO.Co�
sation provisions of the Labor Code, you must,foHkwith comp- LAWN SPRINKLER SYSTEM �- LL _3
ly•with such provisions or.this"permit shall be deemed revok- STATEe—/ C CLASS C 1
ed. WATER HEATER LICENSE N ! O T
LICENSED CONTRACTORS DECLARATION DISTRIC7�O PROCESS �Y
I hereby affirm that am licensed under provisions of Chapter l GAS SYSTEM OUTLETS n6
9(commencing with Section 7000)of Division 3-of the Business OUTLETS OVER t
fed Professions Code;.and my license is-in full force and ef- 5 PER SYSTEM. FINAL VALIDATI
r C 3� . DATE 0
License Number �� 7`a Lica Class V
Cc
'nIra04 ate 01ZZ 0 9 S 3 A �
E I am exempt under Sec.
# 06 005. • UJ
B.&P.C. for this reason Plan check--fee ► I o•.° 9 u 5.0
Date: PLUMBING PERMIT ISSUING FEE $ Sz
o 0 -:9 U 5 0
Signature
TOTAL FEE
.
HOMEOWNER-BUILDER DECLARATION Plan check'applicant I, 0,
SINGLE FAMILY 1 9 g 8
I hereby affirm that I am exempt from,the Contractor's,License Name
Law for the following reason (Section 7031..5,`Business and
Professions,Code): Address
0 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 of that there is a'construction lending agency for
the performance of the work for which this permit is issued,
(Sec.3097; Civ..C.). r
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
ardinaand State laws.regulating Plumbing, and hereby
a orize r presentatives of this County to enter upon the
above- en oned op rty for inspection purposes. .
SEE REVERSE FOR EXPLANATORY LANGUAGE
ign ure of Permitll0e Date