HomeMy Public PortalAbout9455 OLIVE ST_Plumbing__ e WORKERS'COMPENSATION DECLARATION 20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT
1;�'iforeby,-ci irm that 1 have a certificate of consent to self in- 76A667A
sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV.8/86)
certified copy thereof(Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS C
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' 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($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- r /z
mit is issued, I shall not employ any person in any manner so SINK CITY .�� TEL. NO. �
as to beco su ect o the Worker' otnpensation s. DISHWASHER CONTRACTOR
./ � . A /rte/ �r �
GL �"
S(
Date pplicant CLOTHES WASHER ADDRESS
NOTICE O APPLI ANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
empti ,you should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRIC IQ.- 'r ROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 5 l/fJ
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL' V IDATION
fect. DATE
License Number Lic. Class V
FINAL �
Contractor Date BY p
F-
❑ I am exempt under Sec. tJ
W
d
B.BP.C. for this reason Plan check fee poll.
Date: PLUMBING PERMIT ISSUING FEE$ ^ /
Signature TOTAL FEE )U/
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION ;2 1 1 7.6 A
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 jf o o q 9
I, as owner of the property, will do the work and the City Tel. No. i o o Q
structure is not intended or offered for sale(Section 7044, 0 0 0 1 b 1:�0
Business and Professions Code). ►
CONSTRUCTION LENDING AGENCY 1 1.21 -88
1 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 I
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 u on the
above-mention d prope1/1'
or inspection urpose).�� �L�rj SEE REVERSE FOR EXPLANATORY LANGUAGE
Signc6ure of Permittee Dat