HomeMy Public PortalAbout9725 OLIVE ST_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION
PBL Ido"/® ION C®® PLUMBING
UMBI G PERMIT
"`1 herebf affirm that I have a certificate of consent to self in- M-002667 DPW aie7 !1 1�6. `a C! 9 A� ff[6 �V1® ®� I�sv.
76A667A
sure,or a certificate of Workers'Compensation Insurance,ora CE 817(REV.8/86)
certified copy thereof(Sec. 3800, Lab. C.) uIII' Company�k��•IYIS �'uiY�
� COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No.f0J
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING a G L
YNCertified copy is filed with the county building inspection ADDRESS 112, I cJr
department.
y /►�. NUMBER FIXTURE OR ITEM @ FEE LOCALITY T� le- Ct
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Date ` t1S O t Applicant Ts%•Bl WATER CLOSET(TOILET) NEAREST ^ ,./ ! l�
CERTIFICATE OF EXEMPTION FROM WORKERS' InG BATH TUB dD CROSS ST. CO �Ll� eS
COMPENSATION INSURANCE SHOWER OWNER M -adem Siqha
(This section need not be completed If the work involved byMAIL
o,,'
tho permit is for ono hundred dollars($100)or loss.) / LAVATORY J ® ADDRESS _DRESS Q 1delfi C,4-
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so SINK �� CITY TeM c TEL. N ftl&
as to become subject to the Workers'Compensation Laws. DISHWASHER _1W A68m •i OW o
CONTRACTOR
Date Applicant CLOTHES WASHER�8 y�N ADDRESS ��.
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption,you should become subject to the Workers'Compen- CITY rMC,p G� TEL. N .g)g 7dr
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM !� 287
ly with such provisions or this permit shall be deemed revok- STATE 9}� �/ LIC.
ed. ` WATER HEATER �P LICENSE NO. 75195 CLASS 13 1
LICENSED CONTRACTORS DECLARATION Le DISTRICT NO. PRO7E,�SED X1'8 O ��,7
I.hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM JL OUTLETS �[ A
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER 0 0 0 0
and Professions Co/dee, and my license is in full force and ef- 5 PER SYSTEMFINAL VALI TION
W003
License Number 7��0 Lic. Class b DAT fect. r 4 o u O
Contractor ? jkkdR -,5 l.nr. Date __4 ;0
o 2 5 2 8 c=i 0
1 am exempt under Sec. 09. 9—9 w
CL
B.BP.C. for this reason
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE 6_2140
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Namef+f�C L ®Y
Law for the following reason (Section 7031.5, Business and
Professions Code): Address
❑ I, as owner of the property, will do the work and the City �+ �y�C J/ Tel. NoA,?.7,2?0299
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.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-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date