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HomeMy Public PortalAbout9813 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 6/137 insure, or a certificate of Workers'Compensation Insurance, 76A667A 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 ti depart�epttF NUM FIXTURE OR ITEM @ FEE CC�,??//1 /� LOCALI Date 7ppli4ant WATER CLOSET v NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. Q COMPENSATION INSURANCE OWNER SHOWER tt '(This section need not be completed if the work Involved by MAILp the permit is for one hundred dollars($100)or less.) LAVATORY DDRESS V 11 certify that in the performance of the work for which this ,permit is issued, I shall not employ any person in any manner SINK C ` TEL.NO. ,so as to become subject to the Workers'Compensation Laws. DISHWASHER OV CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS + NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CI TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM WA with comply with such provisions or this permit shall beSTATE qS LIC. r deemed revoked. WATER HEATER no LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION TRICr CJROCESqEq BY I hereby affirm that I am licensed-under provisions of Chapter 9 GAS SYSTEM OUTLETS �• (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION DATE hhh 07C License Number �-�✓/� . Class CJ FINAL Contractor Date BY ❑ I am exempt under Sec. ILLI BAP.C. for this reason Plan check fee t�l� Date: � PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE D Plan check applicant SINGLE FAMILY 5 HOME OWNER-BUILDER DECLARATION Name �•ra� I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business.and 7 9�u�� Professions Code): City Tel. No.❑ 1 ITEFis I, as owner of the property, will do the work and the structure is not. intended or offered for sale (Section ® TOTAL �'�.1010 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CHECK 90M 1 hereby affirm that there is a construction lending agency for n�� the performance of the work for which this permit is issued ME (Sec. 3097, Civ. C.). Lender's Name M1—OM1 9/ 6/E9 Lend ' ddress 5543 1 AM1908 II(ove ify that I have ead this application and state that the d information is correct. I ee to comply with all County 00.onces and State laws ru ting Plumbing, and hereby authoriz ressentatives o th' County to enter upon the a ove-menti ed property for i spection purposes. DO SEE REVERSE FOR EXPLANATORY LANGUAGE 6 Signature of Perm a Date J '