HomeMy Public PortalAbout6019 PRIMROSE AVE_Plumbing__ WOBKER'SCOMPENSATION JDECLARATION 787A1N
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APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self Insure,
oF,a certificate of Worker-s Compensation Insurance,or a certified
copy thereof(Sec.3800 Lab.C.)
COUNTY OF LOS ANGELES, DEPT.OF PUBLIC WORKS = .'DEPT.OF,PUBLIC WORKS DIV.
Policy No. Company ,
❑ Certified copy is hereby furnished. BUILDING `
FOR APPLICANT TO FILL IN(PRINT OR TYPE)❑ ADDRESS Certified copy is filed with the county building Inspection
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY T Q
Date Applicant WATER CLOSET NEAREST
CROSS ST. +
CERTIFICATE OF EXEMPTION FROM WORKERS' !� BATH TUB
COMPENSATION INSURANCE ASSESSOR �y��/
(This section need not be completed If the work Involved by the SHOWER MAP BOOK .7 PAGE PARCEL
permit is for one hundred dollars($100)or less.) 3 LAVATORY OWNER
I certify that In the performance of the work for which this permit MAIL
Is issued, I shall nat employ any person in any manner so as to , SINK ADDRESS
become subject to the Workers'Compensation Laws.
/ DISWASHER CITY TEL.NO.
Date (Vr
rApplicant CLOTHES WASHER• NTRACTOR
NOTICE TO AP LICANT:•'If, after making this Certificate
Exemption,you should become subject to the Workers'Compensati n SWIMMING POOL RECEPTOR
provisions of the Labor Code,you must forthwith comply with su DDRESS Lare, o
provisions or this permit shall be deemed fevoked.. LAWN SPRINKLER-SYSTEM �c
LICENSED CONTRACTORS DECLARATION j ITY10
TEC.N
I hereby affirm that I am licensed under provisions of Chapter 9 1 WATER HEATER Q
(commencing with Section 7000)of DIXIslon 3 of the Business and GAS SYSTEM OUTLETS LCENSE NO. O CLLASS
Professions Code,and my license is in full force and effect.
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,`V n OUTLETS OVER DISTRICT PROCESSED BY
/ r 2` 5 PER SYSTEM
License Number ` _ Lic.Classy T f`
FINAL nyr
r DATE /p� VAH6iTf0N WW
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Contractor ate w 33133
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' 1 am exempt under Sec. BY AL I ITEMS �
B.BP.C.fort 's re Pian check fee , 'RITALI 273. 601
/1 CASH 273.6''LL
PLUMBING PERMIT ISSUING FEE$ //
❑ Sig TOTAL FEE 3 GEi(I�!(1E ,l�11
Plan check applicant
_'JSINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name I GODOl-011L! 12/20/94
I hereby affirm that I am exempt from the Contractor's License Law �,
for the following reason(Section 7031.5, Business.and Professions Address '3263i A111J='J,1
Code):
❑ City Tel.No.
I,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). ,
i
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 tate a regulating PI bing, and hereby authorize
repre as r upon the above-mentioned
pr art s r SEE REVERSE FOR EXPLANATORY LANGUAGE
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