HomeMy Public PortalAbout10243 NADINE ST_Plumbing__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT {�
7lerel ,.Sffrpi tha4 I have a certificate of consent to self 76A667A u
insure or o.cert,f,cote of Workers Compensation Insurance CE 817(REV 10/81) _
or a certified copy thereof(Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished BUILDING
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE)
Certified copy is filed with the county buildingADDRESS
inspec
tion department NUMBER FIXTURE OR ITEM FEE
LOCALITY
WATER CLOSET /�
Date Appl,4ant v NEAREST � N
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB O CROSS STit e
pit
COMPENSATION INSURANCE SHOWER OWNER S1 AIeloH,9MJCHgAT
(This section need not be completed If the work Involved by IL
qq e h
the permit is for one hundred dollars(:100)or less) ' LAVATORY ADDRESS Oma N A i/ H S T
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CITY t M 4P C,r TEL NO 373..J,0t6
so as to become subject to the Workers Compensation Laws DISHWASHER
A _ CONTRACTOR
Dates-A3-fb applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making this Certificate of ,
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth CITY TEL NO
with comply with such provisions or this LAWN SPRINKLER SYSTEM
p y p permit shall be STATE LIC
deemed revoked / WATER HEATERoO LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED00 Y
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 0 Q
(commencing with Section 7000)"of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINALFIDATE
VAUDATI
License Number Lic Class 9f,
FIN (�
Contractor Date BY
❑ 09
I am exempt under Sec O
B 8P C for this reason Plan check fee QW,
Date PLUMBING PERMIT ISSUING FEE$ Q Z
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant
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
Prof ions Code) City Tel No �5 3112 A
I as owner of the property will do the work and the # • • • e • 5
structure is not intended or offered for sale (Section
7044 Business and Professions Code) j 1 e * 4(1 5 0
CONSTRUCTION LENDING AGENCY _ e - 412500
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued o a 2 b±8 6
(Sec 3097 Civ C )
Lender s Name
Lender s Address
I certify that I have read this application and state that the
above information,s correct I agree to comply with all County ► i
ordinances and State laws regulating Plumbing and hereby
authorize representatives of this County to enter upon the ,
above mentioned property fo inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
JP
Signature of Permettee Date