HomeMy Public PortalAbout10409 MILOANN ST_Plumbing__ WORKERS'COMPENSATION DECLARATION 20-0026 DPW 4/90 APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of cogsent to self in- 76A667A
sure,or a certificate of Workers'Compensation Insurance,or a
certified cdpy thereof(Sec. 3800, Lob. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
❑ Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 0 Q 0q I b N►p�V ST'
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM @ FEE
department.
LOCALITY
Date Applicant WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. fq_L Q LQ 6U, rr
COMPENSATION INSURANCE SHOWER OWNER SD t4 �� 14 ��KG
(This section need not be completed if the work Involved by MAIL fl g e n
the permit is for one hundred dollars($100)or loss.) LAVATORY ADDRESS U 6r��'�1 L O,4 N fJ S'i'r
I certify that in the performance of the work for which this per- SINK CITY—r— LG r TEL. NO. (I(�L J_(��/
mit is issued, I shall not employ any person in any manner so Q
as to become subject to the Workers'Compensation Laws. DISHWASHER 7
CONTRACTOR
Date. Applicant CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS ;o
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
fect. HOSE BIB DATE
License Number Lic. Class a
FINAL F I c 0
Contractor Date BY t�C:t:��
_ c
F1a
I am exempt under Sec. •'
B.&P.C. for this reason g '
r9 74.�'1 W
Plan check fee ® TTE6 w
Date: PLUMBING PERMIT ISSUING FEE$ Trl i€aL "�� 1-� z
Signature TOTAL FEElot _
SINGLE FAMILY /a CHECK 7�;°±`-i
HOME OWNER-BUILDER DECLARATION Plan check applicant
rNG 0
1 hereby affirm that I am exempt from the Contractor's License Name
Low for the following reason (Section 7031.5, Business and
Professions Code): Address 010100-1000 1 6/ 5/95
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, 0772 1 411110:10
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, ON. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with oil County
ordinon es and State laws regulating Plumbing, and hereby
author' representatives of this County to enter upon the
above entioned oWty, n pection purposes.aO _ se SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature y
Peree Date