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Home My Public Portal About5020 SERENO DR_Plumbing__ WORKERS COMPENSATION DECLARATION 0�00TpA�4/SO APPLICATION FOR PLUMBING PERMIT . I hereby,affam that I have a certificate of consent to self m- 96A067� lure,or V certificate of Workers Compensation Insurance,or a L ' r certified copy thereof(Sec 3800, Lab C ) ful Policy No Company COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS ❑ Certified copy is hereby furnished BUILDIN5G ❑ FOR APPLICANT TO FILL IN(PRIM OR TYPE) Certified copy a filed with the county building inspection ADORE5 department NUMBER FIXTURE OR ITEM b FEE LOCALITY Dote Applicant 3 WATER CLOSET(TOILET) / NEAREST Q �,L.�c CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS Sr ,i`OiFIV 4h COMPENSATION INSURANCE SHOWEROWNER KIw (This section need not be completod H the work Imrclvsd by MAIL 4H /wr the permit Is for ono hundred dollars(1111100)or toss) LAVATORY ADDRESS 2P3 FA0kjI!E ALE I certify that in the performance of the work for which this per- SINK CITY P C TEL NO jJT—fb3J mit is issued, I shall not employ any person in any manner ao as to become subject to the Workers'Compensation Lows DISHWASHER CONTRACTOR Date Applicant ` CLOTHES WASHER ADDRESS NOTICE TO APPLICANT If after making this Certificate of Ex- SWIMMING POOL RECEPTORemption you should become subject to the Workers'Compen- CITY TEL NO sction provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok- STATE UC ed f WATER HEATER LICENSE NO CLASS LICENSED CONTRACTORS DECLARATION I DISTRICT NO D PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS OQ 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION fact 3 HOSE BIB DATE License Number Uc Class G FINAL ACCT.i V tr Conactor Date BY 3303 284.900 I am exempt under Sec JJW1 ITEMS h" U B&P C for this reason Plan check fee ► TOTAL 284 -901!Da'° PLUMBING PERMIT ISSUING FEE$ a D GECK 284.90 Signature TOTAL FEE (} .00 SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION PP I hereby affirm that I am exempt from the Contractor's License Name 0000-0001 6/11/96 Law for the following reason (Section 7031 5, Business and 6838 1 At11U�32 Professions Code) Address -- 1, as owner of the property will do the work and the City Tel No structure is not intended or offered for sale(Section 7040, , 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 o issued (Sec 3097 Civ C ) Lenders 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 Iowa regulating Plumbing, and hereby outhori2p representat of this County to enter upon the above- emit a prop for inspection urpcses SEE REVERSE FOR EXPLANATORY LANGUAGE S,gnakirPbf Permittee Date