HomeMy Public PortalAbout6008 ROWLAND AVE_Plumbing__ W?RKER'SROMPENSATION DECLARATION 7We7 DPW 9/89 APPLICATION FOR PLUMBING PERMIT
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I hereby affirm"that I have a certificate of consent to self Insure,
or o csrt(ficate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.C.)
Policy fg�1I9�'ompan - ._�� (. COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
❑ Certified copy is hereby furnished. �7— f3
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county build' inspection ADDRESSaw
department. NUMBER FIXTURE OR REM @ FEE LOCALITY
Date _a y�pplican WATER CLOSET •� tib NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
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COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work Involved by the ] SHOWER / MAP BOOK PAGE
3 ARCEL
permit is for one hundred dollars($100)or less.) ,f dl 9 OWNER We,
I certify that in the performance of the work for which this permit LAVATORY
is issued, I shall not employ any person in any manner so as to SINK MAIL i
become subject to the Workers'Compensation Laws. l ADDRESS
] DISWASHER CITY 1 1 4 k j;0CTEL.NO.
Date Applicant CLOTHES WASHER CONTRACTOR y�/� i
NOTICE TO APPLICANT: If, after making this Certificate of f t 1Z 1,e—'
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR i �
provisions of the Labor Code,you must forthwith comply with such ADDRESS ``g V3, l ^D
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provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO. f d
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER
(commencing with Section 7000)of Division 3 of the Business and ' GAS SYSTEM OUTLETS / LICESTATNSE NO. �� — 7j CLASS C V
Professions Code,and my license is in full force and effect.
OUTLETS OVER v,�f DISTRICT i S Q
n /+� 5 PER SYSTEM •O✓"e'�-�
License Number oL�1^�3 Lie.Class L� 3 �i'65 ,[ Q
Z DAAVALIDATION a
Contractor m"PA Date I D 5 (/j
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❑ I am exempt under Sec. /
FIN ACCT
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CC l e 4
B.&P.C.for this reason -,
Date: Plan check fee pop. 3307 308.36
Signature PLUMBING PERMIT ISSUING FEE$ 0?/7/ 1 ITEMS
❑ TOTAL FEE 15.09196TOTAL. 308.86
SINGLE FAMILY Plan check applicant CHECK 398.$6
HOME OWNER-BUILDER DECLARATION Name CHANGE .00
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5, Business and Professions Address
Code):
❑ City Tel.No. 000I..000 f 30/29i
1,as owner of the property,will do the work and the structure
Is not intended or offered for sale(Section 7044, Business 6258 1 P11 1:38
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 thi County to enter upon the above-mentioned
property for in on p rposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Ctnnafura of Parmitt n Data