HomeMy Public PortalAbout9802 RICHMOND WAY_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have o certificate of consent to self 20.0026 DPW 6/87
insure, or a certificate of Workers'Compensation Insurance, 76A667A
or o certified copy thereof(Sec. 3800, Lab. 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
Certified copy is filed with the county building inspec- ADDRESS
tion department NUMBER FIXTURE OR ITEM @ FEE LOCALIT
2e- Cdfj
Date Appligant WATER CLOSET _a NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CROSS ST.
Z ell
COMPENSATION INSURANCE SHOWER OWNER ]
(This section need not bo complated If the work Involvod by MAIL
the pormit is for one hundrod dollars($1100)or loss.) LAVATORY ADDRESS
I certify that In the performance of the work for which this
permit is issued,I shall not employ any person in any manner SINK CITY 717
`' TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRALTO
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS
SWIMMING POOL RECEPTOR 09
Exemption, you should become subject to the Workers'
Compensaton provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CI71t` TEL.NO
with compiy with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER in (D LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRI NO PROLE SED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is in full force and effect. 5 PER SYSTEM FINAL ALIDATIOftI
DATE t/
License Number M2 Lic. Class 0
FINAL
Contractor Date BY IY
O
❑ I am exempt under Sec.
B.BP.C. for this reason Plan check fee OeZ
Date. PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE I go 166
SINGLE FAMILY
Plan check applicant
c,!
HOME OWNER-BUILDER DECLARATION Name A,p.h�a
I hereby affirm that I am exempt from the Contractor's License Address Ihalr4T°0
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. M497
❑ 1, as owner of the property, will do the work and the 1 ITM
structure is not intended or offered for sale (Section
7044, Business and Professions Code). TOTAL VE o(013
CONSTRUCTION LENDING AGENCY C*lr,,C6( . 90.0
1 hereby affirm that there is a construction lending agency for l
Aykv
the performance of the work for which this permit is issuedsy
(Sec. 3097,Civ. C.).
Lender's Name ��
1 certify that I have ad this application and state that the $°
bove information is orrect. I ree to comply with all County
ort}i ances and St laws gu ting Plumbing, and hereby
author representatives of this County to enter upon the
r/above-m tioned propert for in ection purposes.
- SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Per i e Date