HomeMy Public PortalAbout5041 SERENO DR_Plumbing__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT ��--II
surepo affum that l have r certificate of consent r self 400028 DPW 6/87 G I
t,gsure or a'carhficate of Workers Compensation Insurance 78A887A lul
of a��r)1���op`�reo1 (Sec 3800 Lob c ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
•YPoh •0 3$ Company ;2�(G�•L PO i r: ' ' • v
Certified copy is hereby furnished BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) i
Certified copy is filed with the county building impec- ADDRESS
lion department ! NUMBER FIXTURE OR ITEM ® FEE
NEARET
Date0414 1 ApphSant WATER CLOSET X62, 145,
NEAREST _
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER OWNER r a
(This section need not be eemplefed R the work Involved by
the permH Is for one hundred dollors (1180)w Iese) LAVATORY =SS �
I certify that in the performance of the work far which this _
permit Is Issued, 1 shall not employ any person in any manner SINK CITY TEL NO �ZL
so as to become subject to the Workers'Compensation Laws
DISHWASHER CONTRACTOR �E•�
Gslh
Data Applicant CLOTHES WASHER
NOTICE TO APPLICANT If, after making this Certificate of ADDRESS D
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- UWNSPRINKIERSYSTEM CITYAli
TEL 20S'10
with comply with such provisions or this permit shall be STATE n LIC
deemed revoked WATER HEATER (CENSE Flo Q" CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO RECESSED v
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS /—a
'(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER y
and Professions Code and my
license Is In full force and effect 5 PER SYSTEM FINAL VALIDATION O:
License Number— M✓ f Lic Clava key- r Q DATE 1I_ (( yL, p
FINAL lY
Contractor /�t ]-�7 S 2"- Date. lf-Vel)"I BY Q
❑ 1 am exempt under Sec i 0
B aP C for this reason Plan check fee Z
° Dote PLUMBING PERMIT ISSUING FEE s a
Signature
' TOTAL FEE
Pion check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Nome
I hereby offum that I am exempt from the Connector s License A:C T
Law for the following reason (Section 7031 5, Business and Address _
Professions Code) City Tel No �-lJ] __722.111
❑ I, as owner of the property, will do the work and the s 1 ITEM:
structureis not intended or offered for sale (Section
70", Business and Professions Code) , TOTAL a272 - 10
CONSTRUCTION LENDING AGENCY _ .HEN!( 2r.1!I
1 hereby affmm that there is a construction lending agency for (� (UE •`�
the performance of the work for which this permit is issued
(Sec 3097 Civ C )
Lender s Name a - �J�rcl!I-�J�1 -1 l a
Lender's Address 2159
,
I certify thatil hove read this application and state that the
above information is correct I agree to comply with all County -
ordmonces and State jaws regulating Plumbing and hereby
authorize reprelentatives of this County to enter upon the
above mentioned property for inspection purposes i
SEE REVERSE FOR EXPLANATORY LANGUAGE
_ /l�_ uzlti/
Signa urs of Permittee Date