HomeMy Public PortalAbout9750 VAL ST_Plumbing__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm have m shot have o certificate of consent to self 76ad67q
Insure or a certificate of Workers Compensation Insurance10.81)
or a certitiffiiedd�cooppy�thereof(Sec 38DO Lab C ) /, COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy Lfo z'L_Company �({v/
Certified copy is hereby furnished
Certified copy is filed with the county building usspec- FOR AFRICAN TO FILL IN(PRINT OR TYPE) BUILDING
Date tlly—/S ✓3 department Applicant /' NUMBER FIXTURE OR ITEM ® _ NEAREST _
LOCALITY T,
WATER CLOSET
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB o2 -� CROSS ST
COMPENSATION INSURANCE SHOWER OWNER 0�
(This section need not be completed if the work Imnishiad by
the permit Is for one hundred dollars($100)or less ) LAVATORY MAIL
/17
1 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
so as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR
Dale Applicant CLOTHES WASHER
ESS F 009
NOTICE TO APPLICANT If, after making this Certificate of SWIMMING POOL RECEPTOR GT�� D
Exemption, you should become subject to the Workers' v L 7 TEL O
Compensation provisions of the Labor Code, you must forth LAWN SPRINKLER SYSTEM O
with comply with such provisions or this permit shall beSTATE LIC
deemed revoked WATER HEATER LICENSE NO CUSS
LICENSED CONTRACTORS DECLARATION DISTRIa.NO PROCESSED BY
I hereby affum that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS Q
(commencing with Section 7ODD)of Division 3 of the Business OUTUTSOVER d
and Professions Code and/my license is in full farce and effect S PER SYSTEM FINAL VALIDATION O
397�y DATE
License Nu ,O7j� Lic Clay/ss�Yp FINAL / O
Connac r .��x'-^-"NE pater/ /�a 3 BY a'Tr' t
❑ 1 am exempt under Sec ' H
B 8P C for this reason Plan check fee Z
Date PLUMBING PERMIT ISSUING FEE S SQ
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s Licenseaddress r 4 5 7 1 A
Law for the following reason (Section 7031 5 Business and
Professions Code) City Tel No • is is is is 5
❑ I as owner of the properly, will do the work and the , 2s s 5 8 5 O
structure is not intended or offered for sale (Section
7044 Business and Professions Code) •,• • 5$5 0 6
CONSTRUCTION LENDING AGENCY
I hereby affirm that there iso construction lending agencyfor 0817-83
the performance of the work for which this permit is issued
(Sec 3097, Civ C )
Lender's Name
Lender s Address
I certify that I hove read this application and state that the P1111,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
a v mentioned operry for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signatur f ermittee Dote