HomeMy Public PortalAbout9925 LOWER AZUSA RD_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that 1 have a certificate of consent to self 20-0026 DPW 6/87
insule, or a certificate of Workers'Compensation Insurance, 76A667A
or a certified coy thereof-(Sec. 3800,tab.,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 Q drn Al
Certified copy is filed with the county building ins ec- ADDRESS f6 �j
tion epart ent. NUMBER FIXTURE OR ITEM ® FEE LOCALITY _
Date2 A Appligont WATER CLOSET 1 NEAREST
CERTIFICATE OF EXEMPTION FROM WO ERS' BATH TUB 00 CROSS ST.
COMPENSATION INSURANCE OWNER
SHOWER
(This section need not be completed If the work Involved by MAIL
tho'pormit Is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK 7150 CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. / DISHWASHER V
CONTRACTOR �
Date oppiicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers',
Compensation provisions of the Labor Code, you must forth- CITY TEL tVO.
LAWN SPRINKLER SYSTEM � v
with comply with such provisions or this permit shall be STATE D3O� LIC. �r
'deemed revoked. / WATER HEATER LICENSE NO. `7�/ O ss
LICENSED CONTRACTORS DECLARATION ,QI TRICT NO. BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (l/ti
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL V LIDA ION
F 4f7
License Number 41V0 ' Lic. Class o1 DAT -�� !� U.
BINAL��
Contractor Date BY
❑ I am exempt under Sec. ()
B.BP.C. for this reason
Plan check fee V)
Dater Z
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL'FEE I f(100
SINGLE FAMILY Plan check applicant
5
HOME OWNER-BUILDER DECLARATION Name ACCT.I hereby affirm that 1 am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and 3W7 118.011
Professions Code): City Tel. No. -
❑ 1, as owner of the property, will do the work and the 1 ITEMS
structure is not intended or offered for sale (Section TOTAL �� w ,
7044, Business and Professions Code). CHECK 11�eUo
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for GWGE Al
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
,
Lender's Name 0WO—OW1 7/ 2/90
Lender's Address 1596 1 AM 9:29
1 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 reprelentotives of this County to enter upon the
above-mentioned'proper for inspectionpuTposes.9
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Pefinittee Date