HomeMy Public PortalAbout10433 MILOANN ST_Plumbing__ /ORKERS'COMPENSATION DECLARATION
20-0026 DPW 4%87 APPLICATION FOR PLUMBING PERMIT
U
.,....�rl:l'(, dffi,m thod I have a certificate of consent to self in- 76A667A
sores or a certificate of Workers'Compensation Insurance,or a CE 817(REV.8/86)
certified copy thereof(Sec. 3800, Lab. C.)
Policy No" Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date Applicant WATER CLOSET.(TOILET) UQ NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST. ' fai
COMPENSATION INSURANCE i �{ U OWNER
SHOWER f7
(This section need not be completed if the work involved by
the permit is for one hundred dollars($100)or less.) LAVATORY MAIL 3'3 E Milcann
ADDRESS
I certify that in the performance of the work for which this per- SINK CITY TEL. NO."7'—
mit is issued, I shall not employ any person in any manner soJi
as to become subject to the Workers'Compensation Laws. DISHWASHER �t CONTRACTOR
Date O�Applicant , CLOTHES WASHER �/v V ADDRESS
NOTICE TO PPLIC NT: If, after ngthis Certificate of Ex- SWIMMING POOL RECEPTOR
emption.,you should become.subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code,you.must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NOPROCESSED BY
I hereby affirm that I am Licensed under provisions of Chapter GAS SYSTEM OUTLETS vfi
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5.PER SYSTEM FINAL / V DATION >'
fect. DATE l rA d
License Number Lic. Class O
FIN W
Contractor Date BY O
i—
I am exempt under Sec. V
W
IL
B.BP.C. for this reason y
Plan cheek fee �
Date: PLUMBING PERMIT ISSUING FEE$ a Q
Signature o o
TOTAL FEE
SINGLE FAMILY 8 b
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
Professions Code): Address
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,
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, Civ. 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 all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned roperty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si a re of Permittee Date