HomeMy Public PortalAbout9503 OLIVE ST_Plumbing__ ' :WORKERS'COMPENSATION DECLARATION... APPLICATION FOR PLUMBING PERMIT
I he eby affirm�n that I have a certificate of consent to self 76A667A
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insure, adf cafe of Workers'Compensation Insurance, CE 817(REV. 10/81)
or a Zertified copy thereof(Sec. 3800; Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company I
Certified copy is hereby furnished. ADDRESS C) ,q r
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) tS D 3 L L(v6,
Certified copy is filed with the county building inspec- I � r
tion department. NUMBER FIXTURE OR ITEM @ FEE
WATER CLOSET LOCALITY-Date
OCALITY CJ-r11
Date Appligant I NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. Gtove 2'Ly `d'i,'1 v h1_
COMPENSATION INSURANCE SHOWER OWNER 1114�fll SCC)ge/ZT
(This section need not be completed if the work involved by 606 MAIL7
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS r 563 0 DI-0161
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY4m / Ci'c
TEL.NO.Z�
so as tobecomesubject to the Workers'�e�mpens tion ws. i DISHWASHER CONTRACTOR ,
Date �V rY!'g Applicant ■ vCLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESSA VL
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code; you must forth- CITY TEL.NO.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT N.71 , ES D BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the BusinessOUTLETS OVER O>.
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VA ATION O
DATE
License Number Lic. Class OC
FIN O
Contractor Date BY U
❑ W
I am exempt under Sec: d
t/!
B.BP.C. for this reason Z
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ a I'
Signature
TOTAL FEE
I Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name —4309. 1 A
I hereby affirm that I am exempt from the Contractor's License Address o 0 0 0 0
P��
g reason (Section 7031.5, Business and # 5
City Tel. No. ) o01 �50
the property, will do the work and the
structure is not intended or offered for sale (Section , o o o 1 6509
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 1 (108-85
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 upon the
above-mentione rope for' spection purposes.
� SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Permittee Date