HomeMy Public PortalAbout4941 SERENO DR_Plumbing__ WORKERS COMPENSATION DECLARATION P'Yg%�_ APPLICATION FOR PLUMBING PERMIT
I hereby7eAW7A affirm that I have a certlllCete of consent to self Insure 7aABB7A
or a certificate,of Worker's Compensation Insurance or a certified
copy therdol(Sec 3800 Lab C)
Policy I COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV
❑ Company
Cemfled copy b hereby tumiehed
❑
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BDULING Cedihed copy M Ned with the county bustling InspectionFOR9
department NUMBER_ FIXTURE OR REM ® FEE LOCALITY
Date Applicant WATER CLOSET 'V; NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERSCROSS STET G V L
BATH TUB
COMPENSATION INSURANCE FASSESSOR
LIP BOOK
(This section Mod not be completed If the work Involved by the SHOWER /� PAGE Q� PARCEL Q
permit is for one hundred dollars(3100)or lap) / LAVATORY OWNER
1 certify that in the performance o work which this permit
is issued I shall not employ any n in an r so as to SINK MAR
become subject to the Workers on tion L AGGRESS
DISWASNER CRY TEL NO
Date tc)pCLOTHES WASHER COffIRACTOR
NOTICE 7 u
APPLICANT If fter ng this C tdncete of
Exsmpbon you should become a lett k Works 'Compansation SWIMMING POOL RECEPTOR
provisions of the Labor Code you at forthwith comply with such ADDRESS
provisions or this permit shell be deemed revoked LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CRY TEL NO }
I hereby affirm that I am,licensed under provisions of Chapter B WATER HEATER
(commencing with Section 7000)of Division 3 of the Business and STATE LIC
Professions Code and my Incense is in lull force and affect OAS SYSTEM OUTLETS iL
LICENSE NO CLASS
OU S OYER DISTRICT NO PROCESSED BY _ I=
S PER SYSTEM n� Q
License Number Lc Claes (/
Fl TL VALIDATION We,
c
ConDATtractor Date E_ y
❑ 1 am exempt under Sac BY
_ FINAL ?
FI
B 3P C for the reason r \
Date Plan check fee ,
Sgmatum PLUMBING PERMIT ISSUING FEE: AT
❑ _ i TOTAL FEE Q
I Plan check applicant ,
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name 11
I hereby affirm that I am exempt from the Contractor's License Law F�lrl.i
for the following reason(Section 7031 B Business antl Professions Address L
Code) I
Tel No
E] I u owner of the property will do the work BM the structure � 1 1 I CMS_
Is not Intended or offered for sale(Section 70" Business
and Prolesams Code) , I 0T 97- 50
CONSTRUCTION LENDING AGENCY (HEC 1K 9".• I
I hereby affirm that there Is a construction lending agency for the C HAA,-3E .00
performance of the work for which this permit to Issued(Sec 3087
Civ C)
Later a Name
Lender a Address 40191 1 AM 9:17
I certify that I have read this application and state that the above - - ►
Inf n is correct I agree to comply with all County ordinances
Stet a gulating Plumbing and hereby authorize
r r eine v o ly County to enter upon the above mentioned
e 1 Inap 6 oee - + -SEE REVERSE FOR EXPLANATORY LANGUAGE r
Nuure P lee Date