HomeMy Public PortalAbout9461 OLIVE ST_Plumbing__ trtirf.le.d.
RKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBINIG.PERMIT
rm that I have a certificate of°,consent to self 20-0026 DPW 6/87
certificate.of Workers'Compensation Insurance, 76AG87A
copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Company
ed copy is hereby furnished. �+
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
ADDRESS (y O /�fI J
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM ® FEE LOCALITY &9 �r
Date Applt4ant WATER-CLOSET 0 NEAREST
CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB t7
COMPENSATION INSURANCE
(This section need not be completed if the work Involved by SHOWER J h✓� 'es '
the permit is for one hundred.dollars($100)or less.) LAVATORY 6(:) ADDMAIL
RESS Cuwt t
1 certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner SINK o CITY TEL.NO.
so as to become subject to the Workers' pe tion Laws. DISHWASHER ��K
CONTRACTOR S LaJ r �. �3�•;i�e
'Dote'-_ Applicant CLOTHES WASHER '
NOTICE TO APPLICANT: If, aft maki this Certificate of ADDRESS
Exemption, you should bec a sub'ect to the Workers' SWIMMING POOL RECEPTOR
P Y I CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER`SYSTEM
with comply.with such provisions or this permit .shall be STATE LIC:
deemed revoked. WATER HEATER LICENSE NO:. CLASS
LICENSED CONTRACTORS DECLARATION D TRICT NO. OCEE,SSED BY
Ihereby cffirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS , O (-\! ✓
(commencing with;Section 7000)of Division 3 of the Business VALIDATION
OUTLETS OVER.
and Professions Code,and my license Is in full force and effect. 5 PER SYSTEM. FINAL
C
License Number Lic. Class DATE, -_4 ' C
I' FINAL
Ilk
Contractor Date BY
❑ I om'exempt under Sec. t.
W
B.BP.C. for this reasonPlan check fee ► CA
Date:
Signature PLUMBING PERMIT ISSUING FEE$
,-,...,., - .
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION' Name
I hereby affirm that 1 am exempt from the'Contractor's License Address
- XCT A -
Law for the following reason (Section 7031.5, Business and
Professions Code): s -- -- 3307 716.50
20"l,
�/ ) City Tel. No.
;12D I, as owner of the property, will do the work and the 1 IT
structure is not Intended or offered for sale (Section. MIL
7044, Business and Professions Code). i p_... _.......•• s.
CONSTRUCTION LENDING'AGENCY CASH 76.50
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CHA�I� A
(Sec. 3097,Civ. C.). o -
Lender's Name t 00Q0-0001 7/19/89 .
Lender's Address - 4555 1 Aft 8144
Icertify 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 Plumping, and hereby
authorize representatives of this County to enter upon the
above-menti d'pro rty for.inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ow-
Si tore of P Ittee Date