HomeMy Public PortalAbout9551 LOWER AZUSA RD_Plumbing__ WORKERS'CbMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I here* affi i that I have a certificate of consent to self 76A667A
insure or c rfif,,ctte of Workers'Compensation Insurance, CE 817(REV 10/81)
or a certif -Copy thereof (Sec 3800, Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
❑ Certified copy is hereby furnished❑ / f FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS � (� r/'�
Certified copy is filed with the county building inspec-
tion department NUMBER FIXTURE OR ITEM FEE
/1 LOCALITY
CJ
Date Appligant WATER CLOSET 1 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB d d CROSS ST
COMPENSATION INSURANCE SHOWER V OWNER I ours
(This section need not be completed if the work involved by MAILp
the permit Is for one hundred dollars($100)or less) LAVATORY ADDRESSC
I certify that in the performance of the work for which this f L
permit is issued, I shall not employ any person in any manner SINK CITY g� C�i TEL NO p
so as to become subl@ct to the Worker Compensa on Laws DISHWASHER /
n S�NLJj CONTRACTOR
Date �y Applic f CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL NO
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER LICENSE NO CLASa
LICENSED CONTRACTORS DECLARATION DISTRICT Vge SSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ^
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER >.
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINALVA DATION n'
DATE �'-2"e V
License Number Lic Class
FIN 09
Contractor Date BY V
❑ I am exempt under Sec W
d
H
B 8P C for this reason Z
Plan check fee
Date PLUMBING PERMIT ISSUING FEE$ 5-L60 �32 1.9 A
Signature
TOTAL FEE G/ # • • • • • 5
Plan check applicantMVLD7t
I • • 34.50
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name • • • 3 4.5 0 L
I hereby affirm that I am exempt from the Contractor's License Address >�� t% I
Q1 8-85
Law for the following reason (Section 7031 5, Business and
(Professions Code) City , Tel No
L1] I, as owner of the property, will do the work and the
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 and state that the ►
above information is correct I agree to comply with all County
ordinances and State lawsregulating Plum g, and hereby
authorize representatives of this Count o enter upon the
above- entio derty for inspe on purposes
i/e_4 SEE REVERSE FOR EXPLANATORY LANGUAGE
,Rnli,
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ignature Permi a Date