HomeMy Public PortalAbout5080 SERENO DR_Plumbing__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hyeby affvm )hat 1,have a cend¢ate of coolant to self 100048 DPW 8l87
insure, oro certiffcate of Workgrs Compensation Insurance 26AS57A
or a cceprnf*copy thereof{Sec lab C ) T COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy Noe (:`a Company J13J Z-t (A jZ1
❑ Certified copy is hereby furnished
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING L� p
Certified copy is filed t county bur ng impec- uuia:ai� O'D llo P
siert deportment NUMBER FIXTURE OR ITEM ® FEE LOCALITY
Daten —Lff 10 Appli, WATER CLOSET D NEAREST
CERTIFICATE OF EXEMPTIO FROM W KERS BATH TUB Q CROSS ST
COMPENSATION INSURANCE
(This""len need not be completed If the work Involved by SHOWER OWNER �+.. .1
the itermH Is for one hundred dollars ($100)or less) S LAVATORY 3 CRESS 10 g N Q z •Q Z'�
I certify that in the performance of the work far which this ^
permit Is Issued, I shall not employ any person in any manner SINK CITY Tn n P TEL NO
so as to become subject to the Workers Compensation Lows ) DISHWASHER
U CONTRA
Date Applicant CLOTHES WASHER �q�s
NOTICE TO APPLICANT If, after making this Certificate of '�""' Is
Exemption, Iyou should became subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM c `^ TEL NO Lima k Lf
with comply with such provisions or this permit shell be STATE LIC
deemed revoked WATER HEATERLICENSE NO O 1 3 CLASS C--
LICENSED CONTRACTORS DECLARATION ICT NO V
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Cade,and my license Is In full force and effect 5 PER SYSTEM
FINAL
Ah/_2 s_9� ALIDATION
cense Number 4St `�- Lic Class C -Z(0 Cv O
I FINAL �yyJ O
C 'v r 1 ' A-16 BY o
❑ ~
I am exempt under Sec (�
W
B 8P C for this reason Plan check fee U)
5 u PLUMBING PERMIT ISSUING FEE f Z
TOTAL FEE D
Plan check applicant
SINGLE FAMILY ACCT.i
HOME OWNER BUILDER DECLARATION Name ,
I hereby affirm that I am exempt from the Contractor s LicenseAddress i '� 112.00
Low for the following reason (Section 7031 5 Business and
Professions Code) City Tel No 1 ITEM
❑ I as owner of the property will do the work and the
structure isnot intended or offered far sale (Section TOTAL 1.1� ��
7041, Business and Professions Code) - , CECK 110,00
CONSTRUCTION LENDING AGENCY C x00
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued ,
(Sec 3097 Gv C )
ODOD-)001 7/31/90
Lender s Name ,
2129 1 An 7:2e
Leader's Address
I teddy that I have read this application and state that the ►
above information is correct I agree to comply with all County '
ordinances and State jowl regulating Plumbing and hereby
authorize repre3ent es of the County to enter upon the
eve mentwned p p ry for mspecIran purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
- a6 - �u
ig oture of Perminee I Date