HomeMy Public PortalAbout9921 LOWER AZUSA RD_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I Kereby affirm that i have a certificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers'Compensation Insurance, 76A667A
or a certified coy�t ereof (Sec. 3800, b.,C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC'WORKS
Policy No. > ✓V Company I i 1 t
Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 11%
Certified copy is filed with the county,building inspec- ADDRESS OL
tion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date Appli4ant 3 WATER CLOSET NEAREST
R IFICATE OF EXEMPTION FROM.WORKE S' BATHTUB CROSS ST.
COMPENSATION INSURANCEOWNER
12,eM ilk
(This section need not be completed if the work Involved by SHOWER
the permit is for one hundred dollars($100)or less.) LAVATORY MAIL
ADDRESS r
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner SINK 10 CITY TEL.NO.4/222
so as to become subject to the Workers'Compensation Laws. / DISHWASHER 5 CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC,
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. SSE BY
I hereby affirm-that I am licensed under provisions of Chapter 9 1 0
GAS SYSTEM OUTLETS �/
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER Q
and Professions Code,and my license is In full force and effect. 5 PER SYSTEM FINALr [/ V LIDATION
F� �I
License Number '/�� lic. Class �s�fa DATE
FIN
Contracto4d&kZ&1&2 Date
9 BY A�/
❑ I am exempt under Seca
0
B.i3P.C. for this reason Plan check fee tfu
o
Date: Z�
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant
1
SINGLE FAMILY s
HOME OWNER-BUILDER DECLARATION Name ACCT.s
I hereby affirm that l am exempt from the Contractor's License Address 3307 118.00
Law for the following reason (Section 7031.5, Business and 1 IT
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the TOTAL 11$ .00
structure is not intended or offered for sale (Section
7044, Business and Professions Code). {,Y, 118.011
CONSTRUCTION LENDING AGENCY ( .00
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.).
000D—OW 1 7/ 2/90
Lender's Name 1597 1 AM 9:29
Lender's Address
I certify that I have read this application and stale that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize reprelentatives of this County to enter.upon the
above-menti ned property for inspection purposes.
� SEE REVERSE FOR EXPLANATORY LANGUAGE
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ignature of Permitt Dbte