Loading...
HomeMy Public PortalAbout9801 RICHMOND WAY_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 insure, or a certificate of Workers'Compensation Insurance, 76A667A lul or a certified copy thereof(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS PolPolicy No.—Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING (WAO Certified copy is filed with the county building inspec- ADDRESS 7 Cffin 0211)� ti department. NUMBER FIXTURE OR ITEM @ FEE J �. LOCALITY Date -6-29 Appli4antP WATER CLOSET NEAREST 'rl CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. (/ COMPENSATION INSURANCE OWNER -/I +Iyl (This section need not be completed If the work Involved by SHOWER - -.- 'I M a e the permit is for one hundred dollars($100)or less.) LAVATORY MAIL ADDRESS I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner SINK 015 CITY--"/ TEL. NO. so as to become subject to the Workers'Compensation Laws. DISHWASHER oV CONTRACTOR �v Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY -i ma-sTEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM 29,63.5 with comply with such provisions or this permit shall be STATE r LIC. deemed revoked. WATER HEATER LICENSE NO. CLAS Z. LICENSED CONTRACTORS DECLARATION DISTRICT NO. PR SSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS a c6Jr O�JS/ (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER V and Professions Codeandmy license is in full forces and effect. 5 PER SYSTEM v FINAL ) _f ALIDATION p> vL.�Y DATE �/ i © C License Ni Lic.Class C; FINAL Contractor Date BY C ❑ I am exempt under Sec. ,'� % t. B.BP.C. for this reason Plan check fee ► U Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE O� SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License �f CT.r Law for the following reason (Section 7031.5, Business and Address Professions Code): City Tel. No. _ ❑ I, as owner of the property, will do the work and the 1 X I I y LL1 structure is not intended or offered for sale (Section006OT sl. Vo m 00 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY GI' Ct CO.00 I hereby affirm that there is a construction lending agency for [s' �i. the performance of the work for which this permit is issued s (Sec. 3097,Civ. C.). Lender's Name 61MID-8m1 9l 6/89 Lender's Address ,5 91 1 A011104 I cert' a read this application and state that the ove informatio is correct. I agree to comply with all County nances and tate la ulating Plumbing, and hereby aut a representatives of is County to enter upon the —above-m tinned property for spe n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Per mi a Dote