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HomeMy Public PortalAbout10169 LOWER AZUSA RD_Plumbing__ s tVihORKERS' CO/v1PENSATiON.DECLARATION APPLICATION FOR PLUMBING PERMIT. -20-0026 DPW 4/87 n I Ffefeby,•affi4 thdf I have a certificate of consent to self in- 76A667A `71u11 =`sura, or a certificate of Workers'Compensation Insurance, or a CE 817(REV.8/86) certified copy,thereof (Sec 0, Lab. C.) Pol,icy.No. ompanjp� COUNTY OF'LOS ANGELES DEPT. OF PUBLIC WORKS y., Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING 101(.9 O1(9 E� S�ST Certified copy is filed with'the count building inspection ADDRESS department. NUMBER FIXTURE OR ITEM @ FEE {//;>) LOCALITY ;�j T Dote �© L t' Applicant WATER CLOSET(TOILET) (3 VV NEAREST BATH TUB CROSS ST. y w CERTIFICATE OF EXEMPTI0 ROM WORKERS" Z (V' COMPENSATION INSURANCE SHOWER., Q OWNER (This section need not be completed if the work involved b'q I/ the permit is for one hunMAIL dred dollars(5100)or less.) 3 LAVATORY, ADDRESS tiZ�pz c'V I certify that in the performance of the work for,which this per- SINK. ,f mit is issued, I shall not employ any person in any manner so �np (/ CITY a�� TEL. NO. as to become subject to the Workers':Compensation Laws. - DISHWASHER - v. CONTRACTOR Date' Applicant / CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, aftermaking this Certificate of Ex- SWIMMING POOL RECEPTOR �� emption; you should becomeaubject to the Workers'C"ompen- CITY L� /f/�p�� TEL. NO. safion provisions of fhe Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ly.with'such provisions or this permit shall be deemed.revok- STATE `/ LIC. ed' 1• WATER HEATER /� �� LICENSE NO. r CLASS C- LICENSED CONTRACTORS DECLARATION i C7 DISTRICT NO. PROCESSED BY I hereby affirm that 1 am licensed under provisions of Chapter GAS SYSTEM OUTLETS 9(commencing with Section 7000)of Division 3 of the'Business OUTLETS OVER 'and Professions Code, and my'license is in'full force and ef- 5 PER,SYSTEM FINAL VALID ON fect. ` rV/�ics DATE O License.Numbe Lic. Class V z'7- ' _ BY. 0 CgrrtractjL�L �- D"ate O 1 am exempt under Sec: Ly LU B.'&P.C. for this reason ► g • Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ S20 9 9 A Signature TOTAL FEE SINGLE FAMILY L # o °'o.o 0,5 HOME OWNER-BUILDER-DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's LicenseName ° o94,50 Law for the following reason (Section 7031.5;'Business and 'o 0 0 9 4 5 0= Professions Code): Address_ •v ❑ 1, as owner of-the-property, will.do;the work' and the City Tel. No. j,0 l 9-88 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 application a'nd 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 ve- enfioned'prop rt for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE lure of Permitt Date