HomeMy Public PortalAbout10011 OLIVE ST_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers'Compensation Insurance, 76A667A
or a certified copy thereof(Sec. 3800, Lab. 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 f
Certified copy is filed with the county building inspec- NUMBER FIXTURE OR ITEM @ FEE
tion department. LOCALITY
Date Appligant WATER CLOSET NEAREST r
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER �y� �-
(This section need not be completed If the work Involved by SHOWER
the permit is for one hundred dollars($100)or less.) LAVATORY MAIL
ADDRESS
I certify that In the performance of the work for which this
permit is issued,I shall not employ any person in any manner SINK CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applican} CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER 50 LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT . \NROCEQED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEMFINAL )/AL'I6Ad10N
DATE ` Q
License Number 11c. Class C3
FINAL 14Li lti
Contractor Date BY ` / 0
❑ 1 am exempt under Sec.
B.BP.C. for this reason Plan check fee
Date: z
PLUMBING PERMIT ISSUING FEE$ 00
Signature � .
TOTAL FEE
SINGLE FAMILY Plan check applicant 5
HOME OWNER-BUILDER DECLARATION Name ;-1CTs4
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address 33,:7 �a[ 1
Professions Code): City Tel. No. y 7t�.T•L
ILCT1! 1 d ;iv
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (SectionI , TOTAL 212t® 00
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CHINK ��oG
I hereby affirm that there is a construction lending agency for �'ir!4r nI[!
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.). {,a 1 )/
Lender's Name
I]l�]Q—C /IC/9111
t' q t J.0dr
Lender's Address
Q011 1 AN t'
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
auth 'ze representativ s of this County to enter upon the
ob• e mention d rorty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�d O L6
Signature of Permitfee f Dat