HomeMy Public PortalAbout9578 LOWER AZUSA RD_Plumbing__ WORKERS COMPENSATION DECLARATION APP CATION OR PLUMBING PERMIT
I hereby Gffvm that I have a certificate of consent to self 20 0026 DPW 6/87
insure or a gertificate of Workers Compensation Insurance 76AS67A
or a certified copy thereof(Sec 3800 lab C ) CO NTY LOS ANGELES DEPT OF PUBLIC WORKS
Policy No Company e „
Certified copy is hereby furnished
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING / O e
Certified copy is filed with the county building inspec ADDRESS f�
tion department NUMBER FIXTURE OR ITEM (� FEE LOCALITY
Date Appligont WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST (/
COMPENSATION INSURANCE SHOWER OWNER Q
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CITY TEL NO
so as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making this Certificate of SWIMMING POOL RECEPTOR
Exemption you should become subject to the Workers CITY TEL NO
Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be I STATE LIC
deemed revoked WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL VALIDATION
—?.3^�L
License Number Lic Class DATE8
' FINAL
Contractor Date BY lz
❑ I am exempt under Sec
B 8P C for this reason Plan check fee
Dote PLUMBING PERMIT ISSUING FEE$
Signature C
TOTAL FEE
SINGLE FAMILY Plan check applicant Ar.If,T,s
HOME OWNER BUILDER DECLARATION Name D17 39.311
1 hereby affirm that I am exempt from the Contractor s License .,
Law for the following reason (Section 7031 5 Business and Address I ITE:,
rof
ons Code) City Tel No
I nT,� 39-30
as owner of the property will do the work and the
atrudture Is not Intended or offered for sale (Section CHECK iii` T
7044 Business and Professions Code) CHMIGE
CONSTRUCTION LENDING AGENCYI t
1 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 124 # AM ?-031
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 laws regulating Plumbing and hereby
uthonze reprelentotives of this County to enter upon the '
e ment ed erty for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date