HomeMy Public PortalAbout5045 SERENO DR_Plumbing__ DEC
t WORKERS'COMPENSATIONI hove
a CION cafe of corse APPLICATION FOR PLUMBING PERMIT
I hereby-a((rrm that I hove a certificate of consent to self 200028 DPW 6/87
ihsure or a certificate of Workers Compensation Insurance, 78A887A ,
or a cerci they of (Sec 38M Lab C ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Poli o_ coI�Company� 54 I — � v
Certified copy is hereby furnished
❑ FOR APPLICANT TO FILL IN(PRIM OR TYPE) BUILDING
Certified copy is filed with the county budding irapec ADDRESS
tion department NUMBER FIXTURE OR ITEM ® FEE LOCALITY �p
WATER CLOSET LG
Dots /Zr�/4�.AppltSant�,��� S NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
COMPENSATION INSURANCE / OWNER
oInvolved
1 ';
(This seAhn need not be completed If the wnv
work Iolved by SHOWER .7
the permit Is for one hundred dollen($100)or leas) LAVATORY MAIL r 0—aw
I certify that In the performance of the work for which this
Permit is issued, I sholl not employ any person in any manner SINK CITYN44) TEL NO 11
so as to become subject to the Workers'Compensation Laws DISHWASHER
CONTRACTOR
Dote Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If cher making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY STATE NO
with comply with such provisions or this permit'shall be STATE ' LIC e
deemed revoked WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION , I DISTRICT NO PROCESSED BY
I hereby afhrm that I am licensed under provisions SYSTEM OUTLETS tons of Chapter 9 / �0
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect 5 PER SYSTEM FINAL VALIDATION
G r O DATE 8
LI_� 7i
License Number 4�.Q � Lic Class
OL,
(l FINAL CE
Contractor AW7f U-A OL, Date (24 �/ j BY O
❑ I am exempt under Sec U
B 8P C for this reason
Plan check fee Z
Date
Signature n�
PLUMBING PERMIT ISSUING FEES Z�
O'c
TOTAL FEE /Q
Plan check applicant
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 '•,?I Ir -'71.'r
Professions Code) Gy Tel No
❑ I}�
as owner of the property, will do the work and the
= hi
structure is not intended or offered for sale (Section
7064, Business pop
TOME 272 - 10 eand Professions Code) - '
CONSTRUCTION LENDING AGENCY ' t.HEO, ' 174.11-
1 hereby affirm that there is a construction lending agency for CHANGE' i,I it 1
the performance of the work for which this permit is issued
(Sec 3097 Civ C )
Lender a Name , r _ 0011 --OOC 1 12l 419 1
r
Lender,s Address i-13��' 1 � _7,:c`7
J .
1 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 repre`:entchves of this County to enter upon the
above menttiioo/nT,ed property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
SignoW of Permit a Dote I'