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HomeMy Public PortalAbout9816 RICHMOND WAY_Plumbing__ I WORKERS'COMPENSATION DECLARATION I APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 20-0024 DPW 6/87 �j insure, or a certificate of Workers'Compensation Insurance, 76A667A IUI or a certified copy thereof(Sec. 3800, Lob. 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 lnspec- ADDRESS do epartmen NUMBER FIXTURE OR ITEM ® FEE LOCALITY a Date Appligant %1� WATER CLOSET D NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB a CROSS ST. —[_ to d COMPENSATION INSURANCE OWNER �Z- (This section need not be completed if the work Involved by SHOWER the permit is for one hundred dollars($100)or less.) LAVATORY MAIL r Q ADDRESSAas I certify that In the performance of the work for which tMn his permit is issued, I shall not employ any person in any manner SINK CIT 7� TEL.NO., 1_ so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACT d� III Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of i Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL. NO with comply with such provisions or this permit shall be STATE �—t/ti LIC. deemed revoked. WATER HEATER ©� LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION / DISTRVk ' OCES D BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 1LJ� C//) (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER f and Professions Code,and my license Is in full force and effect. 5 PER SYSTEM FINAL V LIDATION License Number � /4 Lic. Class r�T� DATE ' U �i FINAL 0 Contractor Date L BY ❑ 1 am exempt under Sec. W B.BP.C. for this reason 0" Plan check fee 0) Date: Z PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE Plan check applicant 5 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name 'T0� I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Address 37 Professions Code): City Tel. No. 1 ITE S ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section ® TOTAL 90.00 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY hereby 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.). MM-Ml 9/ 6/89 Lender's Name I�t�e7� 4Lr� Lender's b 1 N111°0 I cer' that I have read this application and state that the a ve informatio s correc. I ree to comply with all County o inancas an tate law reg acing Plumbing, and hereby ou rize representatives of thi County to enter upon the bove entioned property for i pection purposes. -_ q_�,o f^� SEE REVERSE FOR EXPLANATORY LANGUAGE !No 0 Sign of Per ee Date �°