HomeMy Public PortalAbout5048 SERENO DR_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMB-ING PERMIT
I hereby affirm dtot-I have a certificate of [onsent b self 76A667A
insure or a certificate of Workers Compensation Insurance, CE 817(REV 10/81)
or a certified copy thereof (Sec 3800 ab C ) i
®
Policy ,'d) /O Ka Pa Om n COUNTY OF LOS ANGELES BUILDING AND SAFETY
'lr"" r
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRIM OR TYPE) BUILDING r
❑ Certified copy is filed with the county budding impec ADDRESS
non department NUMBER FIXTURE OR ITEM ® FEE _
Date /-/-7TfGJ�N�ifJ rll.G yf-� WATER CLOSET J /Y ✓
eL NEAREST l• /-
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER OWNER p�
(This asidlun need not be completed R the work Imrohad by 71(
the permff Is for one hundred dollen MAn
($100)or Ion ) 8 LAVATORY MAILADD / f
I certify that in the performance of the work for which this
permit is wised, 1 shall not employ any person in any manner 46SINKCITY �,� TEL NO O V
DISHWASHER as to become subject to the Workers'Compensation Laws A'77 O
DISASHER 3L
CONTRACTOR
F `e_
Date Arplicont CLOTHES WASHER 3ADDRESS /�
NOTICE TO APPLICANT If after making this Certif,mte of SWIMMING POOL RECEPTOR �' A..
Exemption you should become subject to the Workers' -�
Compensation provisions of the Labor Code, you must forth CITY TEL NO !J.
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STA
LIC
deemed revoked WATER HEATER LICENSE NO 7 CLASS (f
��
LICENSED CONTRACTORS DECLARATION DI
SfRK:T BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM -OUT m
(commencing with Section 7000)of Division 3 of the Busie OUTLETS OVER
and Professions Cade,and my license is in full force and effect 5 PER SYSTEM FFlgAt_7 _ VALIDATION IL
License Num er. c1f 2 Class C 3 TEE�� U
,�
p �
Contractor t `e Date. _-Z FIB O
❑ 1 am exempt under Sec Vie
d
B 8P C for this reason Plan check fee
111.7�/ ?
to PLUMBING PERMIT ISSUING FEE$
S gnatur (ja
TOTAL FEE
Plan check applicant
SINGLE FAMILY 30? 7A
HOME OWNER-BUILDER DECLARATION Name - v Jr
1 hereby affirm that I am exempt from the Contractor s License Address 2 4 8 Q FJ 0
Law for the followingreason Section 7031 5, Business and
Professions Code) pry Tel No
. .
I as owner of the r � 480506
property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code) PooOt7 2 7,-8A
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for whch this permit is issued
(Sec 3097, Cit C )
Lender's Name
Lender s Address
I cenify that I have read this application and state that the ►
above information is correct I ogres to comply with all County
ordinances and State laws regulating Plumbing and hereby
author, representatives of his County to enter upon the
abo - enigned pro erM inspection purposes
j SEE REVERSE FOR EXPLANATORY LANGUAGE
ature o Permute 7�-Date