HomeMy Public PortalAbout5082 SERENO DR_Plumbing__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT � �I
I hereby pffem that I have a certificate of consent to self 200026 DPW 6/B7 • G 1
insure or a certfrtate,of Workers Compensation Insurance. ,76A667A lul
or a certified copy thereof(Sec 3BOO, Lab C ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
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D�No 'ao-( P_mr.�l .1�Compai[yA1 1 t O _
Certified copy is hereby furnished ADID�RESS�LV o p
FOR APPLICANT TO FILL IN(PRINT OR TYPE) O
Certifiedcopy n fled with the county budding utspec-
hon department NUMBER FIXTURE OR ITEM ® FEE LOCALITY
T
Date " (�� ApphSon WATER CLOSET NEAREST
- - CERTIFICATE OF EXEMPTION FROM WOkKEkS �o+_j BATH iva ' - CROSS ST '
COMPENSATION INSURANCE
(This section need not be completed if the work Inwlved by t� SHOWER CAVtR tense C �.s t
thi permit Is for one hundred dollars ($100)or toss) LAVATORY MAIL
ADDRESS 10KC Z V
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CITY,\ey,\ s TEL NO
w w to become subject to the Workers Compensation Laws DISHWASHER
CONTRACT l � c Q`c
Dote-------------Applicant CLOTHES WASHER n
NOTICE TO APPLICANT If after making this Certificate of SWIMMING POOL RECEPTOR ADDRESS J)rA 4<_L_ b
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code you must forth- LAWN SPRINKLER SYSTEM CITsp C L� I TEL Natk3_l U i,\
with comply with such provisions cr this permit shall be STATE LIC
deemed revoked WATER HEATER LICENSE NO aoilb l.3 CLASS C -
LICENSED CONTRACTORS DECLARATIONRIgyCy,� BY
I hereby off um that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �J/ V X
(commenting with Section 7000) of Division 310f the Business OUTLETS OVER (1 }}
and Professions Code,and my license is In full force and effect 5 PER SYSTEM FINAL s q VALIDATION a
c2 3 (3 C �� DATF V I Q
�}{License Nu r I/y� �p .. Lic Class
'Contradtoi ` Date I l8-cTZ1 BY FINAL (�'//�^'"'
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I am exempt under Sec U
Ls!
8P C for 1Me,town a'
Plan check fee Z
Dale
PLUMBING PERMIT ISSUING FEES "
sir
TOTAL FEE
• Plan check applicant J
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Name
I hereby offirm that1 am exempt from the Contractor s License
Law for the following reason (Section Address 7031 5 Business and M7 103.GO
Professions Code) City. Tel No 1 ITEMS
❑ I, m owner of the property will do the work and the
structure is not intended or offered for sole (Section TOTAL 103 .00
7044 Business and Professions Code) �. �ry/
CONSTRUCTION LENDING AGENCY DECK 103.011
1 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 ) ,
Lender s Nome ODDO--W V 1 7/31/90
Lender It Address 2133 1 AM 7:24
1 certify that I have read this application and state that the ;
above information a correct agree to comply with all County
0a
oucea and Stat ws r&gula ing Plumbing and here
thoriby
uthorize reprelenl es of this County to enter upon the ,
ove montane openy for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
(8 41AA
g ature of PermitDote