HomeMy Public PortalAbout10206 OLIVE ST_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby,a rm that I have a certificate of consent to self[ri- 20-0026 DPW 4/90
fj 7eA667aA" .
suYe,or a cerfifizate of Workers'.Cpmpensation.lnsuaant�,ora �
certified copy thereof(Seca Q0, Lab. C6
Policy No. mpany COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby fur
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING /(e J,` �O 5'&
Certified copy is filed wit a count ilding inspectio � ADDRESS (J(p ` �/V Nf u
department. ��jj NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Ci
Date �/"a/-/ Applica WATER CLOSET(TOILET) !•
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKE S' BATH TUB CROSS ST. •
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by MAIL ���
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS I
I certify that in the performance of the work for which this per- SINK CITYTEL. NO.
mit is issued, I shall not employ any person in any manner so r7 ct
as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR 00
Date. Applicant CLOTHES WASHER ADDRESS gpl,
N
OTICE TO APPLICANT: If, after making this Certificate of Ex-em tion, ou should become subject to the Workers'Com en- SWIMMING POOL RECEPTOR
P Y I P CITY TEL.Nsation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATELIC.
ed. WATER HEATER LICENSE NO. . CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSEb BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS' S
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER d
and Professions Code, and m license is in full force and ef- 5 PER SYSTEM FINAL
fect. 1. Y , . VALIDATION
f/-- , 3 HOSE BIB DATE a
License Number /w Class _ ry/�
FINAL A44T.r V
i
Contract r Y D e BY r{ jyp�
1. 3303 188.300
I am exempt under Sec. I ITEMS V
B.&P.C. for this reason Plan check fee ► TOTAL . JL88 a'30�
Date: PLUMBING PERMIT ISSUING FEE$ 0 CHECK 188,3 7
Signature TOTAL FEE1rjE
9. 3r� .00
SINGLE FAMILY � •
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name 0000-0001 11/27/95
Law for the following reason (Section 7031.5, Business and
Professions Code): Address 3431• 1 AMID-20
1, 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 y t at have read tFj application and state that the ►
above in
ation is corrf I. I agree to comply with all County
ordinances and State laws r igulating Plumbing, and hereby
authorize representatives o this County to enter upon the
-mentioned property f r` ecti n purposes.
Z;ature
/f_ _�� SEE REVERSE FOR EXPLANATORY LANGUAGE
of Per it Date