HomeMy Public PortalAbout5043 SERENO DR_Plumbing__ WORKERS COMPENSATION DECLARATION I APPLICATION FOR PLUMBING PERMIT
9 hereby pfflrm that I have a certificate of consent to self 40-0048 DPW 6/87
i4sure oc a certificate of Workers Compensation Insurance 76AS67A ,
w o/certified copy there f(Sec 38W Lob C ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Pohc�lYB 01)6 Company._J:f
�Certlfied copy i hereby furnished 1 `1
❑ Certified copy a filed with the county budding inspec- FOR APPLICANT TO FILL IN(PRINT TYPE) BUILDING
ADDRESS
tion deportment NUMBER FIXTURE OR ITEM ® FEE
LOCALITY
Date Appli(ontWATER CLOSET NEAREST ,
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CROSS ST
COMPENSATION INSURANCE OWNER -
(This"dion need not be completed If the vork Inwlved by SHOWER
the permit is for one hundred dollars $100 or leu MAIL
W ( ) J L4VATORY
I certify that in the performance of the work for which this ADDRESS
`permit Is issued I shall not employ any person in any manner - SINK CITY TEL NO . �Z Z
so at to become subled to the Workers Compensation Laws DISHWASHER 1A
J CONTRACTORAWT 4-57'
Date Arplicont CLOTHES WASHER AV 571—
NOTICE TO APPLICANT If, after making this Certificate of ADDRESS IVs9
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
NO
Compensation provisions of the Labor Code, you must forth LAWN SPRINKLER SYSTEM CITY TEL
with comply with such provisions or this permit sholl be STATE I LIC
deemed revokedWATER HEATER / LICENSE NO CLASS C-
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby off nm that I am licensed under provisions of Chapter 9OAS SYSTEM OUTLETS p
(commencing with Section 7000) of Division 3 of the Business Olt s SOVER
saand
and Profeons Code,and my license Is In full force a d)effect 5 PER SYSTEM FINAL p VALIDATION 0:
License Number
_Lic Class e M r DATE TIG V I L
�� FINAL
Contractor-M/l �i 27 e/0/ Dote (�Wf) BY e.s
❑ I am exempt under Sec �� S Ira��'j71
B 8P C far this reason
Plan check fee 1100 z
Date PLUMBING PERMIT ISSUING FEE$ Z
Sipmture
TO1AL FEE a ]
SINGLE FAMILY
Plan check applicant '
ACCT.t
HOME OWNER BUILDER DECLARATION Name ` � t t
I hereby offirm that I am exempt from the Contractor s license Address -1- ]i,jll
Law for the following reason (Section 7031 5, Business and
Prof_vuio n,Code) City Tel No '� _ t 1 ITC-11S
❑ 1, as owner of the property will do the work and the
structure is not intended or offered for sale (Section TOTAL 272 - 10
7044 Business and Professions Code) ti HEi l( 2K.LI
CONSTRUCTION LENDING AGENCY .. lHf�t{l7E ,IJIl
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 ) ,
11r1[lif-fl[IL11 1�/ rt/Yi
Lender a Name
Lender's Address '
I certify that I have read this application and state that the
above mformat ori is correct I agree to comply with all County
ordinances and State jaws regulating Plumbing and hereby
authorize reprelentatives of this County to enter upon the ,
above mentioned pro airy for inspection purposes .
. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Dote r `