HomeMy Public PortalAbout9614 LOWER AZUSA RD_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
insure, or a certificate of Workers'Compensation Insurance, CE 817(REV 10/81)
or a certified co y thereof (Sec 3800, Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy Nj Company S
r_1 Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
�ertrfied copy is filed with the county building inspec- ADDRESS
tion department NUMBER FIXTURE OR ITEM (g� FEE LOCALITY
Date Appli4ant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by MAIL
the permit Is for one hundred dollars(5-100)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
CONTRACT S_J � L je
Date Applicant CLOTHES WASHER
eEl
NOTICE TO APPLICANT If, after making this Certificate of ADDRESS -
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY L' TEL NO ,?S
—
Compensation
comply with such provisions or this permit shall be STATED LIC
deemed revoked WATER HEATER LICENSE NO ti-goCLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PR 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 a
and Professions Code,and my license is in full force and effect 5 PER SYSTEM FINALDAT �/�M�6 y� VALIDATION 0
License Number
�db��Lic Class "' �•+r Q U
FINAL OL
Contractor el C-r-1 Date 12?9 BY mas O
❑ I am exempt under Sec G Q 7/
B EP C for this reason
Plan check fee Z Z
Date PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE �3 S 3.2 A
SINGLE FAMILY
Plan check applicants • • • 05
HOME OWNER-BUILDER DECLARATION Name 2 • • 1450
1 hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031 5, Business and o Q • 16505
r
Professions Code) City Tel No❑ 07,20-83 72d 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 polo
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
obove-mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
0 41
Signature of Permittee ` Dote