HomeMy Public PortalAbout4700 H MILLER DR_Plumbing__ VtgRK)RS'COMPENSATIONDECLARATION ` 20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT
,Ir hereby,Affirm thdT I have o'certificate of consent to self in- 76A667A
'sure,or a certificate of,Workers'Compensation Insurance;or a CE 817(REV.8/86)
certifiedcopy thereof(Sec. 3800, Lab. C.)
Policy N0-.0489.604Company-M .InS• CO• COUNTY OF LOS ANGELES DEPT.. OF PUBLIC WORKS-
Certified copy is hereby furnished. t
Y FOR.APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
`} I Certified•copy is filed with the county building inspection ADDRESS
LJ department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date 6721-91 Applicant n Bros• Plmb WATER CLOSET(TOILET)
NEAREST
�
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER •Olsen DdVeIPMMt
SHOWER
(This section need not be completed if.the work involved byMAIL •
the permit is for one hundred dollars•.($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK CITY MOTIYOV]3 TEL. NO3rJ9-3211
mit is issued, I shall not employ any person in any manner so
-as to become subject to the Workers'Compensation Laws. DISHWASHERS..
• CONTRACTOR ..Cxqm '
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
en ption,you,,should become subject to the Workers'Compen- CITY• ' `MOntrt'_ TEL. NO: 443-0078
sation'provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE 741LIC. t-3115-20-16'.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. _.,PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS n y�
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER lJQ
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION >
fect. DATE _ — 116O
License Number 231-. •741 Lic. Class Ci36-20-16 1 V
OWEffi BrOS.• T111b 6-21-91hW- .LFINAL o
Contractor DateBY
0 I am exempt under Sec. LLI
B.&P.C. for this reason
Plan check fee ,
Date: PLUMBING PERMIT ISSUING FEE$
Signature TOTAL FEE
47—
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License' Name �,
Law for the-following reason (Section 7031.5, Business and A CIC{,F
Professions Code): Address -' 95.50
Lai37
I, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044, I =
Business and Professions Code). ® OTA 95.50
CONSTRUCTION LENDING AGENCY ?5.5f,
I hereby affirm.that there is a construction lending agency for
t CHECK •
the performance of the work for which this permit is issued "HANGS
(Sec. 3097, Civ. C.).
Lender's Name l l€l _iIIJCi$ 6 214%f+;
` Lender's Address 76,57 1 AM 91.134
I certify that I have read this application and state that the
above information is correct. I abree to comply with all County
yudinances and State laws regulating Plumbing, and hereby
thorize representatives of this .County to enter upon the
ffabove-mentioned property,for inspection purposes. -
6-21-91 SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ture of Permittee Date