HomeMy Public PortalAbout9802 WINDSOR LN_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a c4i tiftcate bf consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers'Compensation Insurance, 76A667A
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy No. Company q n rV
Certified copy is hereby furnished. v
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS •
tion department. /�// � j NUMBER FIXTURE OR ITEM @ iFEE LOCALITY
Date —fir— Appligant4� Y-T 1n14 P/4"•✓a 3WATER CLOSET IS O NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB la 00 CROSS ST.
COMPENSATION INSURANCE v`� OWNER
(This section need not be completed if the work Involved by SHOWER �t�S71C�c7 +�[�
the permit is for one hundred dollars($100)or less.) LAVATORY I q (DV ADDRESS ,0" .'�'/ ✓.
I certify that in the performance of the work for which this /
SINK O 0v CITY ' TEL.NO. -'.3�3
permit is issued, I shall not employ any person in any manner e, TEL.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
qq�� CONTRACTOR �1LJ,,�¢j1
Date Applicant � CLOTHES WASHER V ADDRESS �
NOTICE TO APPLICANT: If, after making this Certificate of 15
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITYTEL.N00"y
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM � ) 01"'� 6-1
with Comply with such provisions or this permit shall be STATE l LIC.
deemed revoked. WATER HEATER LICENSE NO. a C�/ CLASS 6-3
LICENSED CONTRACTORS DECLARATIONDISTRICT NQ ROLE D BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ' Y
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER r i1 (J
DA 5
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM vV FINAL AA V LIDATIO[d
//_ DATE 'V
License Num/�b�er�� �P,,������ Lic.Class
(SLC, �lG r�c�o: �/_ FINAL
Contractor Date BY O
❑ I am exempt under Sec. W
B.&P.C. for this reason Plan check fee ® Oe
CA
Date: �
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE O
SINGLE FAMILY
Plan check applicant
,
HOME OWNER-BUILDER DECLARATION Name - 1y�r4TaL
I hereby affirm that I am exempt from the Contractor's License ' Address ICT
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No.❑ 1 I5 I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section ® T �wi)_ 910m
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY1 Ss i�y. � 9Dc00
I hereby affirm that there is a construction lending agency for /a, qtr
the performance of the work for which this permit is issued u00
(Sec. 3097, Civ. C.).
Lender's Name 9/ 6/89
Lender's Address I T A11110107
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-mentio ed property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date