HomeMy Public PortalAbout5039 SERENO DR_Plumbing__ WORKERS'COMPENSATION cats of once APPLICATION FOR PLUMBING PERMIT
I hergbf+ QffIrm that I have a certificate of consent to self TO 0026 DPW 6/87
omFs�ogo 0,-jb cerhficote of Workers Compensation Insurance 76A667A '
P-r esrt,fIedWpyt7�f (Sec 3800 Lob C ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
al f o Company 6titilf 6LA _
Certified copy is hereby furnished
❑ FOR APPUCANT TO FILL IN(PRINT OR TYPE) BUILDING �O
Codified copy is filed with the county building inspec ADDRESS
lion�deportment -� NUMBER FIXTURE OR ITEM ® fEE LOCALITY
DoteAppllSanl \ WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' 6 BATH TUB 3, CROSS ST
COMPENSATION INSURANCE SHOWER OWNER I
(This sedlon need nor be completed if the work hwolved by L
the permit Is for one hundred dollars(1;100)or bas) LAVATORY ADDRESS Q / ZO-• ,
I certify that in the performance of the work for which this
permit is Issued 1 shall not employ any person in any manner SINK CRY TEL NO 0 1Z
so as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR
4-0-3-
Date
- SDate CLOTHES WASHER
NOTICE TO APPLICANT If after making this Certificate of ADORE5550,0 `
Exemption, you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth- , CITY TEL NO j O.$ O
with comply with such p LAWN SPRINKLER SYSTEM
p y provisions or this permit shall be STATE UC G
deemed revoked WATER HEATER LINSE NO CLASS
2L6 I
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS , O G
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER O �`
and Professions Cade,and my license is in full force and effect 5 PER SYSTEM FINAL VALIDATION
License Number Lic Clan
r DA
TE Lb
FINAL
Contractor ?� G-1JDate —f owl 5' BY 1j L
' O
❑ I am exempt under Sec
B 8P C for this reason
Plan check fee En
Dote ^ ?
PLUMBING PERMIT ISSUING FEES oiL.
Signature
TOTAL FEE
Plan check applicant i
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s License Address
Law for the following reason (Section 7031 5 Business and
Profenions Code) City Tel No 3717 272, lV
❑ 1 as owner of the property, will do the work and the 1 F i tlI�
structure is not intended or offered for sole (Secljon '
704 Business and Professions Code) TOTAL 272 - 10
CONSTRUCTION LENDING AGENCY _ i_(ILr�� �7y•11l
I hereby affirm that there is a construction lending agency for r[ha
the performance of the work for which this permit is issued CHANGE _
(Sec 3097, Civ C )
Lender s Name 01130-LJl_01 12/ 4/11
Lender's Address i [1-370 1 AM Opcy�
I certify that I have read this application and sate that the
above information is correct I agree to comply with all County '
ordinances and Stale laws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
above mentioned property for inspection purposes
J( SEE REVERSE FOR EXPLANATORY LANGUAGE ,
V
Signature of Perm lee Dote I - `