HomeMy Public PortalAbout5111 SERENO DR_Plumbing__ .I fwr' y, WORKERS'
��COMPENSATION tDECLARATION Of cosst to pelf in 20OD26 DPW 090 APPLICATION FOR PLUMBING PERMIT
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syre,or,a SeftLfmate of Workers CompeSnaaaon Insurance,ora n
f cgr iced copy fete"Of
( BDD, Lab 7 COUNTY OF LOS ANGE DEPT. OF PUBLIC WORKS
Policy No' V Impany _TAW r vs'•Y ,
MCertified copy is hereby furnished
( ❑I� CertFOR APPLICANT TO FILL IN(PRINT OR TYPE)Certified copy isfiled writ the county building inspection NUMBER FIXTURE OR ITEM ® Fff r ADDRESS department IOCALITV
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Appl scant 2 WATER CLOSET(TOILET) C' {
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Dtlte 127 J
CER`TIF—ICA`TTEi 'OF EXEMPTION FROM WORKER BATH TUB CROSS ST
COMPENSATION INSURANCE ER OWNER
SHOWER
(This section seed not be mmpleted R the work Invoked by MAIL
the permit Is for orte hundred dollar($100)or less ) LAVATORY ADDRESS
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so SINK CITY TEl Lfj� A3
as to become subject to the Worker Compensation Laws DISHWASHER _
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen Cm TEL NO
action provisions of the Labor Code you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC
ed WATER HEATER I LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS Df
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
fact /����.q�7 HOSE BIB DATE IZ-ibq� >
License Number�L¢ Class
ll pr3wlu r _ 112-112— / FINAL V
Contractor tiKL-TDate (P BY •t
I am exempt under Sec pJag ACC f.t
B 8P C for this reason 77!2 '-��" ,..57•�Ic
rchmk
ee ,
Date MBING PERMfT ISSUING FEE s _ 1 1 TEME
Signature 70TAL FEE I01 A' 28'9 ' 05
SINGLE FAMILY p CHEN S9.CYt
HOME OWNER-BUILDER DECLARATION licant 6 9,QS
I hereby affirm that I am exempt from the Contractors License Name T CHANIZ '130
Law for the following reason (Section 7031 5 Business and
Professions Code) Address
Fj I, as owner of the property, will do the work and the Cary Tel No
000[1-0001 6/30/5+
structure is not intended or offered for sale(Section 7044 cQW 1 AM ?:1-6
Business and Professions Code)
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 3097, Civ C )
Lender's Nome
Lender's Address
I certify that 1 have read this application and state that the ,
above information is correct I agree to comply with all County
ordinances and State laws regulating Plumbing and hereby
authorize representahves of this County to enter upon the
obove-mentioned properly for inspection purposes
el 1" !_ !.,_qq- SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature ofPermit G• Date