HomeMy Public PortalAbout5317 NOEL DR_Plumbing__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
ffvrp thpt I have a certificate of consent to self 76A667A
certiflcote of Wbrkers 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 WC4 ompany s Vn y
Certified copy is hereby furnished fm * BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) gDDRESS OEL
Certified copy is filed with the county building inspec NUMBER FIXTURE OR ITEM FEE
ti d rtment LOCALITY /y��tC e
Date Appli4ant WATER CLOSET O NEAREST
RTIFICATE OF EXEMPTION FROM WORKERS BATH TUB O CROSS ST 0,4VZ- S'T'
COMPENSATION INSURANCE SHOWERO OWNER �., ��� &)a f�
(This section need not be completed if the work involved by
the permit is for one hundred dollars($100)or less) LAVATORY MAIL r&i D�L /�
Q D ADDRESS
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINKCITYyP�� /f TEL NO 6���
so as to become subject to the Workers Compensation Laws DISHWASHER G►
CONTRACTOR J'igD
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making this Certificate of SWIMMING POOL RECEPTOR
Exemption you should become subject to the Workers CITY TEL NO 9` _6 JI b
Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL V VALIDATION O
DATE 0
License Number YoUll Lic Class
OG
FIN A O
Contractor 741) 4*wAn .ate BY V
❑ W
1 am exempt under Sec N
B&P C for this reason Plan check fee 111111. Z
Date PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE 14411 fl,00
SINGLE FAMILY Plan check applicant
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s License a1 Address 3 7 2 A
Law for the following reason (Section 7031 5 Business and
Professions Code) City Tel No # 0 rr e • • 5
❑ I as owner of the property will do the work and the
structure is not intended or offered for sale (Section10. 1 e e64.50
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY e • is 6 4.5 0 6
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued 0 106-86
(Sec 3097 Civ C)
Lender s Name
Lender s Address
I certify that I have read this application and state that the 10,above information is correct I agree to comply with all County
ordmonces and State laws regulating Plumbing and hereby
outhonzee��representatives f this County to enter upon the
ab :Zrition proper for inspection pur oses
SEE REVERSE FOR EXPLANATORY LANGUAGE
-4
natur of Permittee ate