HomeMy Public PortalAbout10539 OLIVE ST_Plumbing__ ` WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I J�ereby; affirhythat I have a certificate of consent to self in- 20-0026
A66677A PW 4/90
sure,or-a certific6le of Workers'Compensation l6surance,or a
certified copy thereof(Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Folicy go.-Company
b ,Ipertified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
F1 Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE C�GLG
� LOCALITY
Drite Applicant WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. �M
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK CITY ? TEL.NO.
mit is issued, I shall not employ any person in any manner so ��
as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL.RECEP70R
emption,you should become subject to the Workers'Compen- CITY TEL.NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER 0
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL1 VALIDATION
fect. HOSE BIB DATE l` >.
License Number Lic. Class ' d
FINAL O
Contractor Date BY 1 Q
I am exempt under Sec. O -3,301-11
-`I 'a �
B.BP.C. for this reason - IJ 134.5' W
Plan check fee ► EL IL
Date: PLUMBING PERMIT ISSUING FEE$ /ob Q Z
Signature
TOTAL FEE TOTAL 134 .55
SINGLE FAMILY
Plan check applicant CHECK 1��.551
HOME OWNER-BUILDER DECLARATION pP CHANGE e�{i
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and
Professions Code): Address J CZ
I, as owner of the property, will do the work and the City Tel. No. 527 i � � pfti:,
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 certify that I have read this application and state that the Poo
information is correct.I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
outhori !p tat* s of this County to enter upon the
abov, ntioned pr, ty for in pection purposes.
.i SEE REVERSE FOR EXPLANATORY LANGUAGE
Ig ture Permittee to