HomeMy Public PortalAbout9927 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
insure, or a certificate of Workers'Compensation Insurance, 76A667A
or a certified copy thereof(Sec. 3800, L90. Co COUNTY OF LOS ANGELES DEPT. OF_PUBLIC WORKS f•
Policy No.R'55T, Company.
Certified copy is hereby furnished. BUILDING
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE)
Certified copy is filed with the county buildin inspe - ADDRESS
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant , WATER CLOSET NEAREST
C TIFICATE OF EXEMPTION FROM WOR RS' BATH TUB 00 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($100)or less.) LAVATORY 3 pa ADDRESS 4 &d J&IMOrld
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK O CITY TEL NO.
so as to become subject to the Workers'Compensation Laws. / DISHWASHER �j V CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
-NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers'. CITY TEL NO
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC. /) 1
deemed revoked. / WATER HEATER U
LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DIJTRILT NQ. BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS D UG✓� Q
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER }}
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION Q;
DATE 60 8"
'�� Q
License Number Lic. Class lG V,
FINAL
Contractor Date 2 BY f,
❑ I am exempt under Sec.
B.BP.C. for this reason Plan Check f@@ Z
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE 717100
SINGLE FAMILY
Plan check applicant 5
'
HOME OWNER-BUILDER DECLARATION Name �CCTeT
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and 3307 118.00
Professions Code): City Tel. No. 9 — 1 ITEMS
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section T'OT'AL 118-00
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CfECK 118.00
I hereby affirm that there is a construction lending agency for CNAME .011
the performance of the work for which this permit is Issued
(Sec. 3097, Civ. C.).
Lender's Name •01 7/ 2/90
Lender's Address 1600 1 A 9:35
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 reprelentatives of this County to enter upon the
above-m tioned.pro ert/fTo inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Per tee D to