HomeMy Public PortalAbout6037 MUSCATEL AVE_Plumbing__ WORKERS COMPENSATION DECLARATION I r,
APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I ha.ve'a certificate of consent to:self ;j6g6G7q
insure, or a certificate of Workers'Compensation Insurance, 10E•'81.7(.REV.10%81.)
or.a certified copy"thereof(Sec. 3800, Lob. C.) COUNTY 00 LOS ANGELES BUILDING AND SAFETY
Policy Company-
Certified copy:is hereby furnished. B
j . FOR APPLICANT 70•FILL.IN(PRINT.OR TYPE) ADDRESS /'.O
Certified•.copy is filed with the county building•inspec-
tion ent.depart NUMBER F.IXTURE.OR.ITEM
�j p / NEAREST
Aoe' / WATER CLOSET FEE'S LOCALITY �t..
.74i Cam-
DAate. li4ant. C �r1 �/r
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CERTIFICATE OF'EXEMPTION FROM WORKERS' BATH TUB. CROSS T: C��
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COMPENSATION INSURANCE OWNER
(This-section need not be completed if the work involved by
SHOWER f� /
IL
the permit fs for one hundred'dollars-($100)or.less.) I LAVATORY ^'� ADDRESS
I certify that in the performance of the'work-for which "this ?
Permit-is issued,.:l:shall not employ any person in any manner
SINK CITY TEL. NO.
.so.as to become subject to the Workers'Compensation Laws.
DISHWASHER CONTRACTOR
Date' .. Applicant CLOTHES WASHER
NOTICE:,TO APPLICANT: .If,'.after making this Certificate of -
ADDRESS —�y
Exemption, you should.•become subject to the Workers' E� �!
' ; SWIMMING POOL RECEPTOR � -
�i CITY a7 TEL.NO,..
my
Compensation provisions of the Labor.Code, you must forth- I �`/
LAWN'SPRINKLER SYSTEM,
with. comply with -such provisions or this permit shall be STATE +�^. 'tic.
deemed revoked. I WATER HEATER LICENSE NO. a' CLASS.
'LICENSED-CONTRACTORS DECLARATION DISTRICT NO. OCESSED BY
1 I hereby affirm that Iam licensed under provisions of Chapter 9 GAS.SYSTEM '
(commencing with Section 7000)of Division 3 of the Business Oi1TLET5OVER y.
',OUTLETS
and Professions Code,and.my license is in full force and,effect: . PER SYSTEM .. .. .. 'FINAL .ice
-
DATE �'
s
Q VA...LIDATION
'License Number //• = Lic: Class V
FI.NA' 119
Contractor
//�/ fTiV Date 7/1 BY
.❑ 1.am exempt under'Sec'._ IL
I vii.:
94P:C.'for this'reason -
Plan check fee _-- - Z
I ,Date:. - � ...�_► ----•�---�--- •-.—�_,-..-
I' I PLUMBING PERMIT ISSUING FEE$ •. ""
Signature
11 TOTAL'FEE
1 Plan:check applicant � �. � g 0 5 4 P
$1NGLE FAIMILY
HOME.OWNER-BUILDER DECLARATION 'Name s 41,0 o"o.o a,;;
I hereby off irm..that I am exempt from the Contractor's License '
Address
Law for the•following.reason .(Section. 7031.5, Business and: t^O� I or.o 2:8 50
Professions Code :
❑ )
CRY �r'FG . Tel. No, `� '
I, as owner of.the'property, .will do.the work. and the u1 r'u,: ;i
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.).
L'ender'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 P.lurrmbing, and. hereby
authorize representatives of this County to enter upon the i
above= .entioned pr ty for inspection purposes.
SEE REVERSE FOR:EXPLANATORY LANGUAGE t
'VolD7 , r7
ignoture of Permittee Date ,