HomeMy Public PortalAbout5235 SERENO DR_Plumbing__ hereby,WORKERS'COMPENSATION certificate
of conwOntJto self in- ��6�v90 APPLICATION FOR PLUMBING PERMIT
7aA667A
sure-or o certitlr
cole of Workers Compensation Insurance,oa
certi6e py thereof (Sec 9800, Lab C-� , COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS `I1L.11�
Policy No Company
Certified co is hereby furnished s
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ,
Certified copy is ed with the county building inspection � S v J
de ment NUMBER FIXTURE OR ITEM '® FEE
LOCALITY
Date App tit _�?Jy�( WATER CLOSET(TOILET) hIEAREST
RTIFI TE OF EXEMPTIO ROM WORKERS' BATH TUB CROSS ST
COMPENSATION I CE SHOWER - OWNER ,
(This section need not M completed R work Involved MAIL _
the permit Is for one hundred doll.,({I or Mss) LAVATORY ADDRESS
I certify that in the performance of the work for ich this per- SINK CITY 1 TEL NO
inn a issued I shall not employ arty person m an corner ao 8 !
m to become subject to the Workers Compensation DISHWASHER
OR
Date Applicant CLOTHES WASHER
RE55
NOTICE TO APPLICANT If, after making this Certificate of Ex SWIMMING POOL RECEPTOR It A4 IY�
emp,an,you should become subject to the Workers'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 t DISTRICT NO pPROCE-I SSFD BY
I hereby ,cin that I ec licensed under siovisiof t e Chapter AS SYSTEM
OV WTtFfS
9(commencing with Section 7000)of Division 3 of the Business O OVER i
and Professions Code, and my license is in full force and of- S T FINAL
fact n� HOSE BIB �v�-, DATE '2?' _V ON Y
License Number �?10 Gc Clow(,i 4
�
' FINAL
CoContractor1`h=��1p^ '� J�/ Dote- / i��. - 8V m �236.IV
^ H
I am exempt under Sec
B 8P C for this reason Ple i eircip 49 N, / ► ^JI 1.( 6
Dote PLUMBING PE6A,q-h?RMKG,FEE$ yy lQ
Signature
SINGLE FAMILY applicant
Plan check co
HOME OWNER-BUILDER DECLARATION I>PI - - U
1 hereby affirm that I am exempt from the Contractor's Lice Name '
Law for the following reason (Section 7031 5, Busin and
Professions Code) Address
❑ I as owner of the property, will do th ork and the Gy Tel No
structure is not intended cr offered for a(Section 70M - - -
Business and Professions Code) , '
CONSTRUCTION LE G AGENCY
I hereby affirm that there is construction lending agency for
the performance of the r for which this permit is issued
(Sec 3097, Civ C )
Lender z Nam
Lender a 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 mentionedprop rty for inspection purposes
t S SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature f Permi4ee Dat '