HomeMy Public PortalAbout9807 WINDSOR LN_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I havq a Sgrtificate of consent to self 20-0026 DPW 6/87 }il
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
Certified copy is hereby furnished. BUILDING ` ,
FOR APPLICANT TO FILL IN(PRINT OR TYPE) t J .
Certified copy is filed with the county building inspec- ADDRESS i� �� _ �j /C
NUMBER FIXTURE OR ITEM
tion deportment. FEE LOCALITY - •�. �� C� j
4
Date -/ Applicant.. - � �'� WATER CLOSET / t NEAREST J f
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 0�f CROSS ST. ?r' _U-Sq i,�( en
COMPENSATION INSURANCE SHOWER OWNER
(This section nood not be complotod If the work involved by `
MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ! � ADDRESS
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner SINK CITY.,,-; )� TEL. NO. f �j
so as to become subject to the Workers'Compensation Laws. DISHWASHER l'
�/T�y�� CONTRACTOR v _ iflk i _ jy.
Date Applicant CLOTHES WASHER (.� ADDRESS L r
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL. NO. 7i
Compensation provisions of the Labor Code, you must forth-
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE �, LIC.
deemed revoked. WATER HEATER % LICENSE NO. _ CLASS
LICENSED CONTRACTORS DECLARATION ��° ,.DISTRICT N PROCE ED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS r�
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER (f
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM °OC' FINAL 1{ ALIDATI®Id
"_ DATE V 0
License Number , / Lic. Class 0
_- •f FINAL
Contractor ��+r Date - BY 2k"
❑ I am exempt under Sec.
Iv r
BAP C. for this reason Plan Check fee
Date: PLUMBING PERMIT ISSUING FEE$ IT
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant l
HOME OWNER-BUILDER DECLARATION Name h: Vr7 oV
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address `07 70o&,)
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section ® OTn1 TED.E0
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY r'_
I hereby affirm that there is a construction lending agency for l3��u�J lf7 .011
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name 1XI'M" g 9f 6/E9
Lender's Address �'A I All 11°07
I certify that I have read this application and state that the
above-4riftiFinario is correct. I gree to comply with all County
ainances ansate laws eg lacing Plumbing, and hereby
thorize representative of t is County to enter upon the
a;8ov entioned property for nspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa of Perm to Date