HomeMy Public PortalAbout9801 WINDSOR LN_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 20.0026 DPW 6/87
insure, or a certificate of Workers'ComR ensotion Insurance, 76A667A
or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy No. Company iZml
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING — )
IXCertified copy is filed with the county building inspec- ADDRESS 'T �7-'
tion department. /yam Z yy- I NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date 89 Appli4antS%r'w ;Z7 ILLS"���0� WATER CLOSET a O �"' 2 �
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB .2 00 CROSS 5.T i�e�• i�;e�%
COMPENSATION INSURANCE OWNER
(This section need not be completed If the work Involved by SHOWER e STS IOJG
the permit is for one hundred dollars($100)or less.) 23 LAVATORY � j ADDMAILRESS
I certify that in the performance of the work for which this
permit is Issued, I shall not employ any person in any manner SINK CITY rI r c T TEL. NO. :3 Cal
so as to become subject to the Workers'Compensation Laws. DISHWASHER 0� r
CONTRACTOR
Date applicant CLOTHES WASHER ADDRESS (247-4 /j
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR ^
Exemption, you should become subject to the Workers' CITY f/! TEL.NO. S
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM /
with comply with such provisions or this permit shall be STATE /ro —CLASS _3��
deemed revoked. WATER HEATER LICENSE NO.
LICENSED CONTRACTORS DECLARATION ISTRIC Nq.,. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS t67 (v(
(commencing with Section 7000 of Division 3 of the Business
( 9 ) OUTLETS OVER
and Professions Code,and m license is in full force and effect. 5 PER SYSTEM �'
my
�r' DATE
VALIDATION
License Number �r/• Lic. Classn=__ C�
FINAL �
Contracto + �� ate — BY O
I am exempt under Sec. W
B.BP.C. for this reason
Plan check fee
Date. PLUMBING PERMIT ISSUING FEE$ 10 5D
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY ACCTMg
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License 3307 90otfii
Law for the following reason (Section 7031.5, Business and Address
Professions Code): City Tel. No. 1 ITEC
❑ I, as owner of the property, will do the work and the TOTAL ?0 o GCD
structure is not intended or offered for sale (Section �y nli�.tn�
7044, Business and Professions Code). �rt 9V
CONSTRUCTION LENDING AGENCY u
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.).
4MUMMI 9/ 6/89
Lender's Name 5540 f Mill-007
Lender's 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 i
above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
f 00
Signature of Permittee Date