HomeMy Public PortalAbout9933 LOWER AZUSA RD_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby offIrm'that I`have a certificate of consent to self 20-0026 DPW 6/87
insure,.or a ceruficote of Workers'Compensation Insurance, 76A667A
or a certified co yhglq,f(Sec 3800, Labs C � COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
PolicyNo 6'/Com n
❑ Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
❑
Certified copy is filed with the county building Inspec- ADDRESS 7
tion parfinenf NUMBER FIXTURE OR ITEM ® FEE LOCALITY
Date If Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WOR ERS' `�+ BATH TUB CROSS ST
COMPENSATION INSURANCEOWNER
(This section need not be completed If the work Involved by SHOWER
ror
the permit Is for one hundred dollars(=100)or less) LAVATORY ADDRESS
I certify that in the performance of the work for which thisW
permit is issued, I shall not employ any person in any manner SINK CITYIUATEL NO
so as to become subject to the Workers'Compensation Laws DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER
or
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 hl,
TEL NO
with comply with such provisions or this permit shall beSTTAA E - IICC /1�i „ ,.�i
deemed revoked WATER HEATER �VQv cA
LICENSED CONTRACTORS DECLARATION DISTRICT W BY
1 hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 50 it
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER }z
and Profealons Code,and my license is In full force and effect 5 PER SYSTEM FINAL J l 'VALIDATION N
License Num Lic Class �� DATE[Q
j FINAL
Contractor�e BY
❑ 1 am exempt under Sec
B&P C for this reason Plan check fee
Date PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant 7
HOME OWNER-BUILDER DECLARATION Name �"��*
I hereby affirm that I am exempt from the Contractor's License Address "'�
Law for the following reason (Section 7031 5, Business and 5-1&17 118.1
Professions Code) City Tel No 1 ITEI'15
❑ 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section s OTAL 118.00
7044, Business and Professions Code) CHECK
118. 1
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for 1` .00
the performance of the work for which this permit is issued
(Sec 3097,Civ C )
Lender's Name 0000-M1 7/ 2/90
Lenders Address 1601 1 AM 9:37
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 reprellentatrves of this County to enter upon the
above-mentioned property or InspectiorM4� �rposea
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Perml ee I Dq#'e