HomeMy Public PortalAbout5233 SERENO DR_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
1 hereby, affirm that I have a certificate of consent to self In- �U90
sure,pr a certificate of Workers'Compensation Insurance,or a 77A - n
certified copy thereof (Sec 3BOD, Lab C ) U
Policy No Company.' �7J�L COUNTY OF LOS ANGELES DEPT. OF'PUBUC WORKS ' 't
Certified copy is eby furnished T
BUIIDtNG
Certified copy Is FOR APPLICANT TO FILL IN(PRIM OR TYPE)filed th the county building inspection ADDRESS S ��
'de/partme(nt NUMBER _ .FlXTURE OR ITEM B FEE LOCALITY
DateL 1¢/N.�Applicant — 71 WATER CLOSET(TOILET) NEAREST
CER FICATE OF EXEMPTION F WORKERS' ZBATH TUB CROSS ST
i COMPENSATION INSURAN SHOWER - OWNER
(This secllon need not hs completed H theeve Ievobred by MAIL 1
the permit Is for ons hundred dollar($100)or ) Z/ LAVATORY ADDRESS
I certify that in the performance of the work for which Is per-
mit Is Issued, I shall not employ any person in any man so SINK CITU A TEL NO
as to become subject to the Workers'Compensation Laws l/
' DISHWASHER CONTRALTO
Date Applicant CLOTHES WASHER -
NOTICE TO APPLICANT If, after making this Certificate of Ex-
emption,you should become subject to the Workeri Compen- SWIMMING POOL RECEPTOR
CTTY
wfion provisions of the labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS TEL
ly with such provisions or this permit shall be deemed revok- UC
ed ( TER HEATER CENSE NOae CLASS C='
LICENSED CONTRACTORS DECLARATION DISTRICT (/ PROCESSED BV
I hereby off mn that I am licensed under provisions;of Chapter NOUTLETSR
UTLETS
9(commencing with Section 70DO)of Division 3 of the Business and Professions Code and my license is In full force and isf- - FINAL / iQATtON
fact /J,�, DATE �Z?License Number�-•Lic Clow ,et „�✓ FINAL 231.60 Com/
Contractor �Date. 1�-( _ 5 BY 3303
❑ I am exempt under Sec �F : 1 ITEM O
B 8P C for this reasonTOTAL 23 1 _60 �
ee s CASH 231.60
Date PLUMB] PERMIT ISSUI E < �.i�,v�� _
Signature ($NGE
TOTAL FEE Q
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan ch applicant GM-0001 6/14/95
1 hereby affirm that I am exempt from the Contra tw s License N e
Law for the following reason (Section 7031 5, Business and _ Ei
M73 � 1 AM •]0
Professions Code) Address '
I, as owner of the property, will do the work and a City Tel No
structure is not intended or offered for sole(Sectio 044,
Business and Profeivi Code) r ►
t
CONSTRUCTION LENDING A _
I hereby affirm that there iso construction lending agency for
the performance of the work for which this permit Is Issued
(Sec 3097, Civ C ) --
lender z Name
Lender'sAddress
I certify that vis read this application and state that the ►
above information Is correct I agree to comply with all County
ordinances and State jaws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
above mentioned property for Inspection pu sets , SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date ,