HomeMy Public PortalAbout5084 SERENO DR_Plumbing__ " WORKERS CQMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT JI
1 I''hereby affirm that I have a certificate of consent io self 200026 DPW 8/87• r
mbure, or a certificdoe:of Workers Compensation Insurance, •76A667A
a
or cent led copy thereof JSec 3800 Lob C
� �/� r O /L COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Pfiky R
oP' corn AL L/ '44-N.;7❑
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(MINT OR TYPE) BUILDING
AOT Certified copy is filed with the county budding mspec- ADDRESS.S—D py
1 e A P_-F,AJ t7
tion department NUMBER FIXTURE OR ITEM ® FEE LOCALITY
WATER CLOSET I Q CIt
Dote�-"f 3 -abAppliSo ' NEAREST "
CERTIFICATE OF EXEMPTION FROM WORKS '- Q're_ BATH TUB CROSS ST
COMPENSATION INSURANCE b SHOWER OWNER ,� -v_.'<.. . ••:' �� ^, -
(This stolon need not be completed R the work Imes red by
the permit Is for oto hundred dollars($100)or less ) d LAVATORY MAIL
I certify that in the performance of the work for which this ,
permit is issued, I shall not employ any person in any manner SINK '� CITY TEL NO
so os to become subject to the Workeri Compensation Laws r> DISHWASHERcar 41(10111�
/
Date Applicant - CLOTHES WASHER ADDR""' '
NOTICE TO APPLICANT If after making this Certificate of ""'-"
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth- LAWN SPRINKLER SYSTEM GTY SD , TEL NO if of L
with comply with such provisions or thin permit shall be1. a.qD 3 (3 LIC
CLASSC--�
deemed revoked , WATER HEATER 6' ICENSE NO
LICENSED CONTRACTORS DECLARATION �C DISTRICT NO BY
I hereby affirm that I am licensed under provisions of Chapter 9 / GAS SYSTEM V OUTLETS
(commencing with Section 7000) of Divnan 3 of the Business OUTLETS OVER
and Professions Code,and my license is in ful l force and effect 5 PER SYSTEM i FINAL V41 DTION
o'�9n3/30- 3L DATE
License Clow
cense Num
---K7 �,as FINAL
'Qon auto/ to a'� ( 3-Q BY �
❑ jam exempt der Sac -�
8$P C for this reason N
Plan check fee
Do ?
PLUMBING PERMIT ISSUING FEE$
to -
TOTAL FEE 06
Plan check applicant , 5
SINGLE FAMILY
•HOME OWNER-BUILDER DECLARATION Name - ACCT.'.
I hereby affirm that I am exempt from the Contractor s License Address
Law for the following reason (Section 7031 5 Business and - 3307 113.011
Profession Code) I City Tel No 1 ITE11S
❑ 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section TOTAL 118 00
70" Business and Professions Code) ' -
CONSTRUCTION LENDING AGENCY - G ECK 113.00
1 hereby affirm that there is a construction lending agency for C .00
the performance of the work for which this permit is issued ,
(Sec 3097, Civ C )
Lender s Name0000-0001 M1/%
Lender s Address _ 2132 1 AM 7.24
I certify that 1 hove read this application and state that the
above information is correct I agree to comply with all County -
ordinonces and State lows regulating Plumbing, and hereby
authorize re a ntatrves of this County to enter upon the _ -
above menu n props or inpechon purposes
- •SEE REVERSE FOR EXPLANATORY LANGUAGE
gnalure Perm Date -� -