HomeMy Public PortalAbout5078 SERENO DR_Plumbing__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT JI
I hereby gffirm that I have a certificate of consent to self 204026 DPW 6/87 I
insure cr a,certificote of Wdrkers Compensation Insurance 78A667A ILI'
or a certified copy thereof(Sec 3600, Lab C )
y� COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Poco DI � `F Compan)rA,ttlss(M dA2S �
py is he1 '
Certified copy furnished
+ FOR APPLICANT TO FILL IN(PRIM OR TYPE) BUILDING '
Certified copy is filed with the county building mspec- ADDRESS`� l' •`�.C•P nAip
hon department }/(J,�.,� r D }� NUMBER FIXTURE OR ITEM ® FEE LIX'JLLITY
Date ta9N Apf��4 —� f - W� WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS oL BATH TUB 0 CROSS Sr
COMPENSATION INSURANCE ID SHOWER OWNE6 2Kn/
s
(This.scneed not be completed If the work Involved br
hen t"7 t L• (�
the perms Is for one hundred dollen(1100)or less ) J- LAVATORYMAIL p \�
I certify that in the performance of the viark for which this
permit is issued I shall not employ any person in any manner SINK CITY rA s� k t TEL NO
so as to become subject to the Workers Compensation Laws
DISHWASHER CONTRACT
Dote Applicant CLOTHES WASHER 750 ADDRESS �$ a �`
NOTICE TO APPLICANT If after making this Celificate of • Sl41MMING POOL RECEPTOR
Exemption, you should become subject to the Workers 1
Compensation provisions of the Labor Code you must forth- LAWN SPRINKLER SYSTEM e. TEL NOIp'1l3-1 O
with comply with such provisions or this permit shall be STATE UC
deemed revoked r I WATER HEATER LICENSE NO 9'� 3(3 CLASS
LICENSED CONTRACTORS DECLARATION DISTR NO PROS BY
I hereby off um that I am Iicerned under provisions of Chapter 9 GAS SYSTEM S OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER v
and Professions Code and my license Is In full force andel effect S PER SYSTEM FINAL ALIDATION
License Numbs f LLic Clain DATE ��� 5�9� 8
0 P QBbte -(8 A� BY���� O
h
I am exempt under Sec 4
N
B 8P a reason_ - ($ Plan check fee , Z
Date
PLUMBING PERMIT ISSUING FEE f07
B'ga 03 oD • s
=11 TOTAL FEE
Plan check applicant `- Ar.�T.i
SINGLE FAMILY _
HOME OWNER BUILDER DECLARATION Name 3307 107is0(1
thereby gffum that I am exempt from the Contractors License Address
Law for the following reason (Section 7031 5 Business and 1 ITEMS
Professions Code) city Tel No TOTAL 103� 00
❑ I os owner of the property will do the work and the
structure is not intended or offered fof sale (Section CHECK 103.00
7044, Business and Professions Code) x�1
CONSTRUCTION LENDING AGENCY '
I hereby affirm that there is a construction lending agency for
the performance of the work for which•this permit is issued
(Sec 3j 97 Civ C ) - 00110"0001 7/.1/90
Lender s Nome •
2130 1 AM 7 2
Lender's Address • -
I certify that I have read this application and state that the
above information is correct 1 agree to comply with all County
or nances and Stote laws regulating Plumbing and hereby
autho z reprellentahves of this County to enter upon the - r
abov mentioned ro rty for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
ign Wre of PermHt P Das-