HomeMy Public PortalAbout9590 LOWER AZUSA RD_Plumbing__ WORKERS COMPENSATION DECLARATION 2APPLICATION FOR PLUMBING PERMIT
I hereky affirm that I have a certificate of consent to self in 76 66;A PW 4/87
sure or a certificate of Workers Compensation Insurance or a CE 817(REV 8/86)
certified copy thereof(Sec 3800 Lab C )
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy No Company
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ,�f � /�
Certified copy is filed with the county building inspection ADDRESS S 0 to W ck 4ZL J
department NUMBER FIXTURE OR ITEM @ FEE LOCALITY
WATER CLOSET(TOILET)
Dare Applicant NEAREST ,�►
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST I r C 1 L
COMPENSATION INSURANCE SHOWER OWNER A Ale 111
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less) LAVATORY ADDRESS I 0
I certify that in the performance of the work for which this per SINKA d
mit is issued I shall not employ any person in any onner s CITY !l Sri TEL NO q` 69
as to become subject to the Workers Compenso Laws
'7 DISHWASHER CONTRACTOR
Date /0— 9A?,,scant • CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT If after making this Certificate of Ex SWIMMING POOL RECEPTOR
44
emption you should become subject to the Workers Compen CITY EL NO
saflon provisions of the Labor Code you must forthwith comp LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok STATE LIC
ed WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO �/ P CESSED BY
I hereby affirm that I am licensed under provisions of Chapter ' GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER C/ C/
and Professions Code and my license is in full force and of 5 PER SYSTEM FINAL VA ATION
fect DATE 13
License Number Lic Class
V
FI �
Contractor Date F
I am exempt under Sec 8 3 AL W
B 8P C for this reason # • • • • • 5
Pian check fee ► 1 4050
Date PLUMBING PERMIT ISSUING FEE$
Signature Q S • • • 4 Q 5 0 c=i
TOTAL FEE
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Plan check applicant 1 0,23&87
1 hereby affirm that 1 am exempt from the Contractor s License Name /�C
Law for the following reason (Section 7031 5 Business and
Professions Code) Address 0 ` d A Z S
I as owner of the property will do the work and the City Tel No96 2
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 oil County
ordinances and State lawIregul g Plumbing and hereby
authorize representativesunty to enter upon the
above mentioned roperttion purposes
JO..�3 47 SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nature ofpermittee Date