HomeMy Public PortalAbout9923 LOWER AZUSA RD_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that f have a certificate of consent to self 20-0028 DPW 8/87
Insure, or a certificate of Workers' Compensation Insurance, 78A887A
or a certifle coy thereof (Sec. 3800, Lob. 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
Certified copy is filed with the county building inspec- ADDRESS O
tion de riment. J NUMBER FIXTURE OR ITEM ® FEE LOCALITY
Date Appli4anT WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORK RS' 2 BATHTUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER —
(This section need not be completed If the work Involved by MAIL
the permit 1s for one hundred dollars ($100)or less.) LAVATORY Q ADDRESS
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL, NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
.CONTRACTOR
Date Applicant CLOTHES WASHER + ADDRESS
JV
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL.NO.
with comply with such provisions or this permit shall be STATE v LIC.
deemed revoked. WATER HEATER LICENSE NO. 77 v / CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO, PROLE D BY
I hereby,affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS O �/
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER o �.
and Professions Code,and my license is in full force
'and
effect.
5 PER SYSTEM FINAL// �/ VALIDATION
License NumberLic. Class DATEC�Z/�/ Q.
FINAL f�
Contractor Date BY 0.
❑ I am exempt under Sec. tU
B.BP.C. for this reason 0.1
Plan check fee. N
Z
Date: PLUMBING PERMIT ISSUING FEE$
Signature 1.
TOTAL FEE '
Plan check applicant c
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name ACCT.4
I hereby affirm that I am exempt from the Contractor's License Address 3307 118.100
Law for"the following reason (Section.7031.5, Business and
Professions Code): City Tel. No. 1 ITEMS
❑ I, as owner of the property, will do the work and the TOTAL JL 1S o 00
structure is not intended or offered for sale (Section
44
70 , Business and Professions Code). ► CHECK 11$x[ I
CONSTRUCTION LENDING AGENCY C
HAME
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.).
OOOO-0001 7/ 2/90
Lender's Name 1599 1 1M 9°32
Lender's Address 7
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
authorize reprelentatives of this County to enter upon the
above-metitinned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of PdFmitiee Date