HomeMy Public PortalAbout9821 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 �j
insure, or a certificate of Workers'Compensation Insurance, 76A667A ILII
or o certified copy thereof(Sec. 3800, Lab. C. COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Policy No. Company i
❑ Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS �
Certified copy is filed with the county building inspec-
tion de artmen NUMBER FIXTURE OR ITEM FEE
r (/�' LOCALIT
Date Appligonl ` -+ fl, WACLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB V' CROSS ST. J ' Id!
COMPENSATION INSURANCEfV+_
SHOWER OWNER IT J1 U00
(This section need not be completed if the work Involved by
the permit is for one hundred dollars($100)or less.) LAVATORY /t' MAIL ADDRESSJr �)
(f �..
I certify that in the performance of the work for which this %�
permit is issued, I shall not employ any person in any manner SINK V CIT ' EL.NO. gf
so as to become subject to the Workers'Compensation Laws. DISHWASHERYv/
CONTRACTOR(' r
Date Applicant CLOTHES WASHER �• —n
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS K
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY TEL.NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall beSTATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT O. CESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code, nd my license is in full force d effect. 5 PER SYSTEM FINAL
rr.� f _ DATE d / ALIDATION per.
License Number �`� Lic. Class CO.7
FINA
Contractor 01 Date BY
❑ 1 am exempt under Sec. V
W
B.t3P.C, for this reason LL'
Plan check fee ®� (nDate: C
I PLUMBING PERMIT ISSUING FEE$ c7
Signature
TOTAL FEE
Plan check applicant /5
SINGLE FAMILY ACC o V
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License 3307 94.00
Law for the following reason (Section 7031.5, Business and Address
1 ITEMProfessions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the TOTAL 90-00
structure is not intended or offered for sale (Section /�.�/
7044, Business and Professions Code). 4C1/{��CK 90I
CONSTRUCTION LENDING AGENCY CORKS 000
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-OMI 9/ 6/89
Lender's Name 5541 1 RS111�07
Lender's7en
ess
I certif have r d this application and state that the
above tion is orrect. I a to comply with all County
ordina d St to laws r ula ng Plumbing, and hereby
authoriz representatives q this aunty to enter upon the
bove-me 'oned property for ins ction purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signbtur rmittee Date