HomeMy Public PortalAbout10227 OLIVE ST_Plumbing__ Lor WOJKER3'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby,.Arm that I have a certificate of consent to self 76AS67A
insueb, or.o certifi5ato of WookeA'Compensation Insurance, CE 817(REV.8/86) l�
or o certified copy thereof(Sec. 3800, Lab. C.)
r 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
Ci
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY
Date Appligant WATER CLOSET L NEAREST + '
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB %7,g 100
CROSS ST. t
COMPENSATION INSURANCE OWNER
d if s�lt-
(This section need not be completethe work involved by SHOWER
the permit is for one hundred dollars($100)or less.) '�� LAVATORY ^� MAIL
ADDRESS I0L S'
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY _ TEL.N n?
so as to become subject to the Workers'Compensation Laws. DISHWASHERCONTRACTOR
�7
Tq
Date Applicant 1 AQ SSU�i.G/W CLOTHES WASHER ADDRESS
NOTief TO AP CANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, ,you should become subject to the Workers' CITY TEL.NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE C.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. P OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 6�`
(commencing with Section 7000)of'Division 3 of the Business OUTLETS OVER �/
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL TION
DATES
License Number Lic. Class
LB
IN
Contractor Date a
I am exempt under Sec. OF �
27*71,7A a
B.BP.C. for this reason Plan check fee
® # a,aoao5
Date' PLUMBING PERMIT ISSUING FEE$ �Q
Signature0 0 3 4 5 0
TOTAL FEE
opRR 5QQ=
Plan check applicant 0H
G TIP-
Plan
SINGLE FAMILY
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
Professions Code): City Tel. No.
J I, as owner of-the property,.will do the work and the -
\ structure is not Intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY t
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 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
authorize representatives of this County to enter upon the
abaft---Mentioned property for inspection purposes.
� � n SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date 3'