HomeMy Public PortalAbout5038 SERENO DR_Plumbing__ • WORKERS'COMPENSATION DECLARATIOIJ . APPLICATION FOR PLUMBING PERMIT
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1 hereby affirm that I have a certificate of cons9nt,to self 7yyp7A
insure or a certificate of Workers'Compensation linurance CL 817(REV 10/81)
or a certified copy thereof (Sec 3800 Lob C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished
❑ FOR APPLICANT TO FILL 1N(PRINT OR TYPE( BDRE
UILDING
Candied copy is filed with the county building inspec- ADSS 0 3
and
hon deportment NUMBER FIXTURE OR ITEM ® FEE
LOCALITY
Date AppliSant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER OWNER 41--'�L.E L. 611_
(Thlsisaction naafi not be completed If the work Involved by
the permit Is for ane hundred dollars($100)or less) MAIL p IL
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner, SINK CITY TEL NO
sa as to beco a sublect to the Workers Compensation,Laws
/' DISHWASHER CONTRACTOR
Date P3 pplicant s� /'�/ t/Q�-u'r/ CLOTHES WASHER
NOTICE APPLICANT If after making this Certificate ADDRESS
Exemption you should become subject to the Workers' SWIMMING FOOL RECEP70R
Compensation provisions of the Labor Code you must forth CITY TEL NO
with comply with such provisions or this permit shall be AWN SPRINKLER SYSTEM
STATE LIC
deemed revoked WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION I DISTRICT NO BY
I hereby off um that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER d
and Professions Code,and my license is in full force and effect 5 PER SYSTEM / FINAL O
License Number Lic Class VALIDATION G- 0. DATE (`! �� V
K
Vr�i+ FINAL I O
Contractor Dale BY
❑ I am exempt under Sec d
N
8 8P C for this reason PIOO CITBCk f@8
Dote 3
PLUMBING PERMIT ISSUING FEE E a
Signature
TOTAL FEE
Plan check applicant ,p 4 9✓�,3 A
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name r
# • • • • • 5
I hereby affirm that I exempt from the Contractor's Licene ,address '
Law for the followingg r reason (Section 7031 5 Business and t '
Professions Code) City Tel No 2,• • 1 650
❑ I, as owner of the property will do the work and the • • 1 650P!
structure is not intended or offered for sale (Section ► i
7044, Business and Professions Code) 0 905-8,3
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 Coy 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 this County to enter upon the
above mentioned property for inspection purpose
®T SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee to