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HomeMy Public PortalAbout5703 RIO HONDO AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION . ' APPLICATION FOR PLUMBING PERMIT I hereby, affym that I have a certificate of convent to,selh in- 20 0026 DPW 4/90 surd,or a certificate of Workers'Compensation Insurance,or a 76A667A certified copy thereof(See 381719, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company Certified copy is hereby furnished. BUILDING �+ FOR APPLICANT TO FILL IN(PRINT OR TYPE) Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM ADDRESS .RF department. @ FEE LOCALITY Date Applicant WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. v COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work Involved by MAIL the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK CITY TEL.NO. mit is issued, I shall not employ any person in any manner so as to become subject to the Workers' mpensation Laws. DISHWASHER CONTRACTOR Date Applicant r � aCLOTHES WASHERADDRESS AfNOTICE TO APPLICANT: If, after makingertificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- CITY TEL.NOa sation provisions of the Labor Code,you must forthwith comp- lw LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok- STATELIC. ed. WATER HEATER LICENSE NO. 73 6 CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. / PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS f / ® JOd �y 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER �L and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL / VALIDATION fect. HOSE BIB DATE (` License Number Lic. Class e�Yo d FINAL Contractor ` Date BY 33031 ITM� 43 Zii I am exempt under SeiT TOTA'" z" I— B.BP.C. for this reason Plan check fee 100. 4s� D e: ` � PLUMBING PERMIT ISSUING FEE$ © n�" Z Signature TOTAL FEE � d Q D-LiIID1 113/ 2/9 SINGLE FAMILY � 73 HOME OWNER-BUILDER DECLARATION Plan check applicant 1 1 hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and Professions Code): Address I., as owner of the property, will do the work and the City Tel. No. structure is not intended or offered for sale(Section 7044, Business and Professions Code). , CONSTRUCTION LENDING AGENCY 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.). Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ► ordinances and State laws regulating Plumbing, and hereby cAhorize re entatives of this County to enter upon the e-men' d rope ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE -4ignature of Permittee Date