HomeMy Public PortalAbout9256 WEDGEWOOD ST_Plumbing__ O KERS."COMPENSATION DECLARATION /�
'1• �_, 20rD026DPW 4/87 -APPLICATION FOR PLUMBING .PERMIT
!tl'(Ze' that I have a certificate of consent to self in- 76A667A
sure,or a certificate of Workers'Compensation Insurance,ora CE 817(REV.8/86)'
cerViffed cop'7thereof(Sec. 3800, Lab.-'C.)
Policy No. Company COUNTY OF LOS ANGELES DEP,!.-PF PUBLIC WORKS'
Certified'copy is hereby furnished. _
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection I ADDRESS 92 $ JA9 'two
o ��o
department. NUMBER FIXTURE OR ITEM @' FEE
LOCALITY
Date - Applicant WATER CLOSET(TOILET) 61aA_ 60
NEAREST
CERTIFICATE OF EXEMPTION FROM'WORKERS' BATH TUB i f CROSS ST. ps'SC
COMPENSATION INSURANCE (. 0 h OWNER XA14—('�. I&f Lee t j-YLt,�N C Lee
SHOWER U ,
(This section need hot.be completed if-the work involved by MAIL f
the permit.Is for one hundred dollars($100)or less.) LAVATORY 6 ADDRESS '.' (,� {i0a1 S
I certify that in the performance of the;worli for which this per- SINK n
as to become subject to the Workers'C pensation Laws. DISHWASHER
ee CONTRACTOR
Date �'f / Appl ica r `.� �. CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT: If, after making is Certificate of Ex- SWIMMING POOL.RECEPTOR
eriiption,.you.should become subject fo t e Workers''Compen- CITY TEL..NO.
sation provisions of the Labor Code,you must forthwith comp- ' LAWN SPRINKLER SYSTEM
ly with.such provisions or this permit shdll be deemed revok. STATE LIC.
ed. -;- • , • WATER.HEATER' L61
LICENSE.NO. CLASS
LICENSED-CONTRACTORS DECLARATION DISTRICT D DISTRICT NO. PROCVED
I herebyaffirm that lam licensed under provisions of Chapter GAS SYSTEM - OUTLETS ,1
9(commencing with.Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions.Code, and my license is in full force'and ef- 5 PER SYSTEM' 'FINAL ` VALI ION
feet. DATE `�
License Number, `Lic. Class O
q. .. FINAL
Contractor Date BY O
F-
I am exempt;under Sec. W•
B.&P.C. for'flis reason oil
H
• Plan check fee •
z1.14,7,A
Date:' PLUMBING PERMIT ISSUING-FEE$
Signature lob # o a o.0 0 5
TAL FEE
SINGLE FAMILY TO
HOME OWNER-BUILDER DECLARATION Plan'check applicant 1 —.8250
I hereby affirm that I am exempt from the Contractor's License Name• x
Law for the,followmg reason (Section.7031..5, Business and ° ° ° 8 2 5 0=5
Professions Code):. Address
` 11, 16-88.
AI; as owner of the property, will do the work,and the City Tel. No.
. structure is not intende4 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,Civ. C.).
Lender's Name,
Lender's.Address
I certify that I'have read this application and state that the ,
aboveinformation-is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize $presentatives of this County.to enter upon the
ab ve- tinned property for ins ction purposes.'
SEE REVERSE FOR EXPLANATORY. LANGUAGE
$Ignatur f Permittee , Date ;