HomeMy Public PortalAbout5730 RIO HONDO AVE_Plumbing__ S'„'/Jy0#-t%W6t5ERS'GOMPENSATIt7N DECLARATION APPLICATION FOR PLUMBING PERMIT
r�I herkbyl affirm that I have a certificate of consent to self 76AB67A
insure, or a certificate of Workers'Corripensation Insurance, CE 817(REV.8/88)
or a certified copy thereof(Sec. 3800,Lib. 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) ADDRESS
Certified copy is filed with the county building inspec- NUMBER FIXTURE OR ITEM � FEE
tion department. 7,ro
LOCALITYC,'
WATER CLOSET •� 6
Date Appli4ant L V NEAREST Q
CERTIFICATE OF EXEMPTION FROM WORKERS' '�-- BATH TUB CROSS ST.
COMPENSATION INSURANCESHOWER / Q OWNERAZ
O L
(This section need not be completed if the work Involved by r MAIL
the permit Is For one hundred dollars($100)or less.) LAVATORY If ADDRESS f-
I certify that in the performance of the work for which this .0
permit is issued, I shall not employ any person in any manner SINK CITY �i T TEL.NO� 1//
so as to become subject to the Workers'Compensation Laws. c` _ DISHWASHER Aww 7
S-15--d-7
�^ c o'' CONTRACTOR
Date v 1`�� Applicant' Z6” CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of .�
Exemption, you should become subject to the Workers' ""��+ SWIMMING POOL RECEPTOR
CITY � TEL. NO.
Compensation provisions of the Labor'Code, you must forth- LAWN SPRINKLER SYSTEM � "/'
with .comply with such provisions or this permit shall be STArE LIC.
deemed revoked. WATER HEATER LICENSE NO. r® CLASS
LICENSED CONTRACTORS DECLARATION I DISTRICT NO. PR ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEMft TLETS �^ /J�
(commencing wirh Section 7000) of Division 3 of the Business OUTLETS OVER ,v
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALID TION O
DATE z-� �j �� y
License Number Lic. Class
t FINAL 9
Contractor Date BY t 0
❑ 1 am exempt under Sec. ILW
B.BP.C. for this reason W
Date:
Plan check fee 00 .
. Z
PLUMBING PERMIT ISSUING FEE$ @ 7 0 5,-3 A
Signature
TOTAL FEE #" 0005 rr '
Plan check applicant I
0 0
SINGLE FAMILY o o�Q y`j Ur
HOME OWNER-BUILDER DECLARATION Name ( IA5
, o515-87
I hereby affirm that I am exempt from the Contractor's License Address
Law for.the following reason (Section 7031.5, Business and .:3 O Ax o
UO
ssions Code): City Tel. No.
I, as owner of the property,.will do the work and the ►
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
authorize representatives of this County to enter upon the
above-n ntioned property f spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
o eC fe Date
i� ��►,�. 7 1. ,u.