HomeMy Public PortalAbout9810 RICHMOND WAY_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUNld`G PERMIT
I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 �j
insure, or a certificate of Workers'Compensation Insurance, 76A667A (I JI
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Policy 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
fin
fi depart NUMBER FIXTURE OR ITEM @ FEE .-
LOCALIT
Date Appli4ant WATER CLOSET IffNEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' hJ
BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER lP
(This suction nood not be completed If the work Involvod by SHOWER
the pormit Is for one hundred dollars($100)or loss.) LAVATORY MAIL
ADDRESS
I certify that to the performance of the work for which this 00
permit is issued, I shall not employ any person in any manner SINK � CI TEL.NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
b D CONTRACTOR
Date Applicant CLOTHES WASHER In 10® ' j r
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY �S' TEL.NO
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. ,,Gg,� CLASS
LICENSED CONTRACTORS DECLARATION DISTRI O� ' OCES ED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS lv
i .01
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is in full force and
effect.
� 5 PER SYSTEM DATE (A ION WQ) C
License Number
Q� FINAL a
Contracto F Date u BY O
❑ 1 am exempt under Sec.
B.BP.C. for this reason
Plan check fee a
Date: 0
PLUMBING PERMIT ISSUING FEE$ 15
Signature
TOTAL FEE 901 oy
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name p�n
I hereby affirm that I am exempt from the Contractor's License Address ACCT.V
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. 3307 90°00
❑ 1, as owner of the property, will do the work and the 1 11as
structure is not intended or offered for sale (Section TOTAL 'PED
1307044, Business and Professions Code).
CONSTRUCTION.LENDING AGENCY cl-am 90.011
1 hereby affirm that there is a construction lending agency for t
the performance of the work for which this permit is issued CHAE 000
(Sec. 3097, Civ. C.).
Lender's Name =—=11 9/ 689
Lend ' ddress4�
rtify that I have r ad this application and state that the
a ve information is correctree to comply with all County
or nces and State law reg sting Plumbing, and hereby
authon repre°sentatives of fh County to enter upon the
above-me -oned property for i ction purposes.
r� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of PermiIt a ate