HomeMy Public PortalAbout5016 SERENO DR_Plumbing__ I Hereby,WORKERS'
ff Rm hatCOMPENSATION a DECLARATION to self In- APPLICATION FOR PLUMBING PERMIT '
20-OM OLIN 4/90
surd,or a cerlificate of Workers Compensation Insurance ora 7AAey7A
certified copy thereof(Sec 9800, Lab C ) i
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Policy No CCOUNTY OF LOS ANGELES DEPT. OF PUBIC WORKS
ompany
Certified copy is hereby furnished `
Certified c is filed with the court building Ins FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUDDING `r
department H g pechon NUMBER FIXTURE OR ITEM ® FEE ADDRESS /b moi- Q n�
LOCALITY
Date Applicant WATER CLOSET(TOILET) /0 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST L
COMPENSATION INSURANCE SHOWER OWNER 1,i '
(This section naafi not be completed If the work InvoWad by ne MAD _e, M�R
this pernilt Is for ohundred dollars($100)or lass) 3 LAVATORY ADDRESS ,M T
I certify that in the performance of the work for which this per !
mit Is Issued, I shall not employ any person in any manner so I SINK Cm —M�AD 1 Q TEL NO
as to become subject to the Workers'Compensation Laws DISHWASHER
CONTRACTOR
Date Applicant f CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If, after making this Certificate of Ex- SWIMMING POOL RECEPTORemption,you should become subject to the Workeia'Comjxn- CITY TEL NO
sahon provisions of the Labr Code you must forthwith comp , LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok STATE UC
ed WATER HEATER LICENSE NO CUSS
LICENSED CONTRACTORS DECLARATION DISTRICT rao p PROCESSED BY
I herebyaffirm that I am licensed under GAS SYSTEM OUTLETS �O
Division
3 of t e Chapter
9(commencing with Section 7000)of Dlwalon 3 of the Business OUTLETS OVER �+c
andProfessions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL `q + p�IC� nON ,,,,�
fact HOSE BIB DATE �- s7 �— 3m O
License Number Llc Class
FINAL 1 ITEMS V
Contractor Date TIL BY TOTAL 301_006
I am exempt under Sec mss 1•DOLE GECK JV V
8 8P C for this reason Plan check fee
Date PLUMBING PERMIT ISSUING FEE$ Q ULJ�
Signature zo
_ TOTAL FEE
SINGLE FAMILY / 6w 0000--0001 6/11/96
HOME OWNER-BUILDER DECLARATION Plan check applicant 6036 1 AM1O:32
I hereby affirm that I am exempt from the Contractor's License Name,
Low for the following reason (Section 7031 5, Business and
Professions Code) Address
I, as owner of the property will do the work and the CIH Tel No
structure is not intended or offered for sole(Section 7044, s ,
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 opplicanon and state that the
above information is correct I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
outhorla represenmt,ves of this County to enter upon the
above nho ed p ojl�p rt or inspection purposes `
6 _/I- SEE REVERSE FOR EXPLANATORY LANGUAGE
Slgnat a of Permmee Dote