HomeMy Public PortalAbout5011 SERENO DR_Plumbing__ �W ' COMPENSATION DECLARATION
y �A APPLICATION FOR PLUMBING PERMIT
r ,Y-he eb affirm im, that I have a certificate of consent to self m- 10 667 DPW�/�
sure,or a certificate of Workers Compensation Insurance or o CE 817(REV 8/86)
certified copy thereof (Sec 3800, Lab C )
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy No Company
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRIM OR TYPE) BUILDING
Certified copy is filed with the county budding inspection ADDRESS -150
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department I NUMBER FIXTURE OR ITEM a FEE
_ LOcnury
Date taApplicant WATER CLOSET(TOILET) O NEAREST �— `
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB d CROSS ST `�
COMPENSATION INSURANCE SHOWER OWNER
(This settlors nand not be completed If the work Involved by MAIL
rhe perrnM Is for one hundred dollars ($100)or lass ) LAVATORY - ADDRESS
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so SINK CITY TEL NO
as to become subject to the Workers'Compenrt, n pws DISHWASHER - G
� ` CONTRALTO
Date Applicant CLOTHES WASHER
NOTICE TO APPUCAN If, after making gh ,�rtil`Zate of ExADDRESS
emption you should become sub eat to thrkers Compen SWIMMING POOL RECEPTORCITY TEL NO
sation provisions of the Labor C e youorthwith-comp LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shodeemed revok- STATE UC
ed WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTR2 NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS vG'^ UT
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER z
fed Professions Code and my license is in full force and of 5 PER SYSTEM
dai
2VALID ION a j� p
License Number Lic Class V
Contractor Date O
I am exempt under Sec W
B&P C for this reason PIOn check fee
Date PLUMBING PERMIT ISSUING FEE$ ;T 9 O O 7 A
Signature # • • a ata 5
-,
SINGLE FAMILYTOTAL FEE I • a 2&5 0
.
HOME OWNER-BUILDER DECLARATION Plan check applicant `
I hereby all that I am exempt from the Contractor s License NameI s a - 2a506
Law far the following reason (Section 7031'5 Business and O GOO-88
Professions Code) Address5-2711
❑ I as owner of the property will do the work and the Ciry Tel No �6
structure is not intended or offered for sole(Section 704 _
Business and Professions Code) '
CONSTRUCTION LENDING AGENCY i ►
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 ) ,
t ,
Lenders Name
}
Lender's Addiess ,
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-mention pr rty f inspection purposes ,
SEE REVERSE FOR EXPLANATORY LANGUAGE
nature f ermi Date