HomeMy Public PortalAbout9070 OLIVE ST_Plumbing__ WORKER'S COMPENSATION of consent to 20.0026 DPW 9/89 APPLICATION FOR PLUMBING PERMIT
1 Aeaebiaffirm that I•have a certificate of consent to self insure, 78A8a7A
or a.cert((icate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.C.
• -� COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
IR
No. ,
�ompany T'j/1
Certified copy is hereby furnished. ADDRESS d
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) (j �
Certified copy is filed with the-count building inspection
Qe�
departure t. NUMBER FIXTURE OR ITEM ® FEE LOCALITY
i
Date Applicant 3 �; WATER CLOSET
NEAREST
CROSS ST.
C RTIFICATE OF EXEMPT N FROM WO RS' BATH TUB
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed If the work involved by the SHOWER MAP BOOK PAGE ) PARCEL�a�
permit is for one hundred dollars($100)or less.) OWNER .. v
I certify that in the performance of the work for which this permit LAVATORY c..
Is Issued, I shall not employ any person in any manner so as toMAIL
SINK ADDRESS
become subject to the Workers'Compensation Laws.
DISWASHER CITY 1. TEL.NO.
Date Applicant CLOTHES WASHER CONTRACTOR ' •
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption;you should become subjectADDRESS
to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such 7r
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM 10 7-H AIM
LICENSED CONTRACTORS DECLARATION CITY TEL N( :�C-192�7}
1 hereby affirm that I am.licensed under provisions of Chapter 9 WATER HEATER J0 '�.
(commencing with Section 7000)of Division 3 of the Business and STATE LIC...
OAS SYSTEM OUTLETS LICENSE NO. C S6.
Professions Code,and my license is in full force and effect. DIST131CT NO: P Q1 BY )_
OUTLETS OVER �. 0
'ins 2 5 PER SYSTEM a s
License Number v� ��` Lic.Class • L_ -
FINAL p� Iii `5 i`f■Z,.WJ
�� DATE/,Z• �'-/� VALID Ti D.
Cont o r ate TOTAL
227.259-�+ (0
IV �—_ FINAL t t.TTL 22 a'' as 25 Z
I am exempt unde c. Y c
B.&P.C.for this reason 116 CffCK
Date: Plan check fee , CHANGE .010
Signature
PLUMBING PERMIT ISSUING FEE$ 4,16-
0-
O❑ TOTAL FEE 5 00.1110-130131 7125 7J
SINGLE FAMILY Plan check applicant 0940 f AM 10 59,,
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5, Business and Professions Address
Code):
City Tel.No.
ElI,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
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. 1 agree to comply with all County ordinances
and State laws regulating Plumbing, and hereby authorize
representatives of this County to enter upon the above-mentioned
i
property f insp ct�u oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
S&dtureot Per to Date