HomeMy Public PortalAbout9104 OLIVE ST_Plumbing__ OR. ERS'COMPENSATION DECLARATION i /
Ie'YebyL ffirm that I have a certificate.of consent to self , �,A ` APPLICATION FOR PLUMB NG PERMIT
({;sure, or.a certificate of Workers'Compensation Insurance, CE 817(REV. •10/81)
or a.certified copy there7o/f}(Sec. 3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No1FJ -1 r company �7 /flk�
❑ Certified copy is hereby furnished. v BUILDING /� ..
5 FOR APPLICANT TO FILL IN.(PRINT OR TYPE) ADDRESS 7 O/ (1.e
Certified copy is filed-with the.county building inspec
tion.departye NUMBER FIXTURE OR ITEM FEE LOCALITY Tn* /Q Or f
Date ' Appl.igant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER A& 9� An S 45111's
(This section need not be completed if the work-involved by MAIL
the permit is for one hundred dollars($100)or less.) I LAVATORY ADDRESS ✓��ll�
I certify that in the performance of the work for which this y,
permit is issued, I shall not-employ any person in any manner SINK CITYpr�! de TEL NO. `3Y
so as to become subject to the Workers Compensation Laws.. DISHWASHERl
CONTRACTOR NOS C Ap r /
Date- Applicant CLOTHES WASHER ADDRESSyy
NOTICE TO APPLICANT.: If,. after making this Certificate of JI /1/Cl/�r%A
' Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY TEL.NO.�f/fr t,
Compensation provisions of the Labor Code, you must forth.- ,, Q � /7✓-p�7�
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE / LIC. (�
deemed revoked. WATER HEATER LICENSE NO. Yogi CLASS a
LICENSED CONTRACTORS DECLARATION DISTRICT NO. P CESSED BY
I hereby affirm that I am licensed,under provisions of Chapter 9 GAS SYSTEM OUTLETS J7` A
(commencing'with Section 7000)of Division 3 of the Business OUTLETS OVER v.
and Professions Code,and my license is in full force and effect. 15 PER SYSTEM FINAL116VAL ATION
ZIA0 3 ? DATE G 0
License Number ` �+S_ Lic:Class C3
FINAL
Contractor �0��02 Date 2-114S'S' BY �7I9
/�
13 1!!
I am exempt under Sec.. �
B:&'R.C. for this reason 4a► �
Plan check fee R 2 9 Q 2 A
Date: PLUMBING.PERMIT ISSUING FEE$ (�
Signature - # o,o. 0005
TOTAL FEE
Plan check applicant
1 16,5.0
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name o o o 1 &5 0 25
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and 09,12-85
Professions Code): City Tel. No.
❑ 1., 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. $097, 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 Plumbiag, and hereby
authorize representatives of this County to enter upon the
above mentioned property fo 'nspection purposes..9-fg�zSEE REVERSE FOR EXPLANATORY LANGUAGE
i -
Signature of Permittee Date