HomeMy Public PortalAbout9521 LOWER AZUSA RD_Plumbing__ P WORKERS' I.haveCOMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
1 hereby, affirm that I,have a cerfificgte of consent to self in- 20-0026 DPW 4/87
76A667A
sure or a certificate of Workers'Compensation•rnsurance,or a CE 817(REV.8/86)
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certified copy thereof(Sec. 3800, Lab. C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
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Certified copy is filed with the county building inspection ADDRESS 7/ YV e
department. NUMBER FIXTURE OR ITEM @ FEE
s LOCALITY C.i O C11
Date Applicant �j WATER CLOSET(TOILET) ( NEAREST
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE OWNER ��G�
SHOWER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY sb ADDRESS 17P PL
I certify that in the performance of the work for which this per- SINKO�C►<<
mit is issued, I shall not employ any person in any manner so CIT R 1lt/CT� TEL. NO.
as to become subject to the Workers'Compensation Laws. DISHWASHER 75V
CONTRACTORdWV Bu/LO��Z
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption,you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR
CITY TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER .ill LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION ✓ `� DISTRICT NO. P CESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 0 , O Z
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
fed,Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL 10)Professions
License Number Lic. Class DATE O
V
FINAL cc
Contractor Date BY O
Fj 1 am exempt under Sec. LU
B.&P.C. for this reason ► U)
Plan check fee �� �
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE D
SINGLE FAMILY Plan check a licant 5T&
(BIZ Y 414`
HOME OWNER-BUILDER DECLARATION PP
1 hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and ACCT.v
Professions Code): LAddress74 5� ��� /QLD AvF.
c 3307 110.510
I, as owner of the property, will do the work and the /�*l e�V TelIca . NdO �-Oz '-
structure is not intended or offered for sale(Section 7044, 1 ITEMS
Business and Professions Code). ► TOTAL 11101.50
CONSTRUCTION LENDING AGENCY CHECK 110.50I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CI ANE—E .011
(Sec. 3097, Civ. C.).
Lender's Name Clow-113001 1/ 2/90
Lender's Address 7939 1 AM11.026
I certify that I have read this application and 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
Aobov enfioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig ure 0
Per ttee Date