HomeMy Public PortalAbout5113 SERENO DR_Plumbing__ .WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
rl hereby,yff rm thbt I have a certificate of consent to self in- 7A' 4/90
Sure,or a certificate of Worken'Compensotlon Insurance,or a y I
certified copy Owreof(Sac , Lab C ) �� r(
Policy No 0 mpony' " 7%"�U COUNTY OF LOS ANGELES DEPT.OF PUBLIC'WORKS'
❑ Certiflpd copy is hereby furnished BUILDING
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FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
ernfied copy is filed with the county building inspection
NUMBER FIXTURE OR ITEM Q FEE LOCAUTY
Data_4�C —p�Y Applicant !:�;J „ WATER CLOSET(TOILET) - NEAREST
Z
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER - OWNER
(This section need not be completed If the work Inwlved by MAIL
the permit Is for one hundred dollars ($100)or less) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- D
mit a issued, I shall not employ any person in any manner so SINK CITY TEL NO L8 S7 :-0 O
as to become subject to the Workers'Compensation Laws DISHWASHER
CONTRACTOR ,rs
Dote Apphmnt CLOTHES WASHER
ADDRESS
NOTICE APPLICANT If offer making ilia Certificate of Es- SWIMMING POOL
emphon,you should become subject to the Worken Compen- CITY TEL NO
sation 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 LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION / DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS p
9(commencing with Section 70DO)of Division 3 of the Business OUTLETS OVER _ O
and Professions Code and my license is in full force and of- S PER SYSTEM FINAL VALIDATION
fact
HOSEBIB DATE (�—'3 _ - d
License Number 6 Lrc Clan 13- FINAL kiCT.i V
ContractorAwd5.1 t73K"k - BY 37303 239.cl�' 6
E] I am exempt under Sec ` 1 ITMz V
4 B 8P C for this reason 5s
Plan check fee ► , T1 �OT2$9 _ O _
DateNUMBING PERMIT ISSUING FEE f CHE K =r'3•I'`
Signature TOTAL FEE Q (Yf{ E •�-1
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Controctoi s License Noma I?u01)-1101]1 E,/--'13/q
Low for the following reason (Section 7031 5, Business and _.�
Professions Code) Address - 5905 1 Arl 9;:
F1 I as owner of the property will do ilia work and the City Tel No
structure is not intended or offered for sale(Section 7044 -
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, Cv C )
Lender s Nome
Lender s Address
I certify that I 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 representatives of this County to enter upon the _
above-mentioned property for inspection purposes
�������� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of of PermmeeV Date