HomeMy Public PortalAbout9217 WEDGEWOOD ST_Plumbing__ �� tKER'SCOMPENSATION DECLARATION Mo8276ADPw9/89 APPLICATION FOR PLUMBING PERMIT
I Newby that 1 have.a certificate of consent to self Insure,
or a•,certi(i2 ted i,Worker's Compensation Insurance, or a certified
copy�Fhered�l�SeC.3800 Lab.C.)
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.-
Policy No. Company
❑ Certified copy is hereby furnished.
❑ � FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certlfied copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM FEE LOCALLY
Date Applicant WATER CLOSET
NEAREST C,
(jam/
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE BATH TUB
ASSESSOR '
` (This section need not be completed If the work Involved by the SHOWER MAP BOOK PAGE PARCEL.
permit is for one hundred dollars($100)or less.) OWNER
I certify that in the performance of the work for which this permit LAVATORY
is issued, I shall not employ any person in any manner so as to SINK ADDRESS ! (
Data Applicant CLOTHES WASHER
NOTICE TO APPLI NT: If, after making this Certificat ONTRACTOR
Exemption,you should become subject to the Workers'Compens ti SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code,you must forthwith comply with s ch
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY• TEL.NO. CL
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I hereby affirm that I am licensed under provisions of Chapter 8 WATER HEATER STATE LIC. a
(commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO. CLASS
Professlons;Code,and my license is in full force and effect. V
OUTLETS OVER DISTRICT NO. PROCESSED BY )Y
5.PER SYSTEM d/ Q
License Number. Lic.Class V
INAL VALIDATION W
J DATE � d
Contractor we r fA
FINAL - Z
❑ I am exempt under Sec. BY
B.&P.C.for this reason
Plan,check fee -'
D te:
PLUMBING PERMIT ISSUING FEE$ d .t •�
T
Signature .. .- .. . Flv':s�
❑ TOTAL FEE
Plan check applicant 1 1TEi l(
SINGLE FAMILY
HOME OWNER-BUILDER DECLAR-AT-IOr Name TOTAL 41.85
1 hereby affirm that I am.exempt from the Contractor's License Law
for the following reason(Secti.on 7031.5, Business and Professions Address CHECK 41.85
Code):
❑ City Tel.No. CHANGE
1,
I,as owner of the property,will do the work and the structure
Is not Intended or offered for sale(Section 7044, Business
and Professions Code). 00011-000 1 12/13/93
CONSTRUCTION LENDING AGENCY 2.974 1 AM 9:26
1 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 Name
Lender's Address
I certify that I have read this application and state that the above Pol.information is correct. I agree to comply with all County ordinances
and State laws regulating Plumbing, and hereby authorize
representativ s of this County to enter upon the above-mentioned
prove for sp ction pur SEE REVERSE FOR EXPLANATORY LANGUAGE
t,', I fltUre O I t t