HomeMy Public PortalAbout9064 RANCHO REAL RD_Plumbing_1985-11-20 WORKERS'I OMPENSATION DECLARATION APPLICATION FORPLUMBING PERMIT
'I hereby alirm that have a certificate of consent to self 76A667A
insure; or aertificaf of Workers'Compensation Insurance, CE 817(REV. 10/81)
or a certified'copy thereof(Sec. 3600, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Compony l•
Pol _�
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING GADDRESS- (�' -Q h-C 6 G `eel. l
Certified copy is filed,with the county building inspec- •�
tion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date Applicarit WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION.FROM WORKERS' BATH TUB CROSS ST. S(
COMPENSATION INSURANCE - SHOWER OWNER �!4
(This section need not be completed if the work involved by
the permit is for one hundred dollars($100)or less.) y LAVATORY ADDRESS SQ 11 C d Ek
I certify that in the.performance•of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY' � e le C r L TEL.NO. a P6• n
so as.to become subject to the Workers'Compensation Laws.
DISHWASHER
•o� CONTRACTOR
Date o pplicant ` J CLOTHES WASHER• ADDRESS '
NOTICE TO APPLICANT: If; after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL.NO.
Compensation provisions of.the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions. or this permit shall be STATE LIC.
deemed revoked.. I WATER,HEATER LICENSE NO: CLASS
LICENSED CONTRACTORS DECLARATIONDISTRICT No )TpCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 i GAS SYSTEM OUTLETS b Q
(commencingwith Section 7000)of I Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FIA
NT L VATION
License Number Lic. Class Z'? y
FI 9E
Contractor Date V
W
I am exempt under Ser. �
B.&P.C. .for this reason �
•• Plan check fee
Date: ►
' PLUMBING PERMIT ISSUING FEE$ Q U
Signature
TOTAL FEE t,6
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Namej c c ' 50
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and x
i 650U
Professions Code): City Tel. No.
I, as owner of the property,, will,do.the work and the ( 1.2 0-8.5
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 ,
/1-11 �i 4�
ignature of Permittev ate