HomeMy Public PortalAbout9810 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/B7
insurg, or a cbrtificate of Workers'Compensation Insurance, 76A667A ILII
or a certified copy thereof(Sec. 3800, Lob. 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) ADDRESS
Certified copy is filed with the county building inspec-
92/6 So tion department. NUMBER FIXTURE OR ITEM ® FEE LOCAUT
�� WATER CLOSET g9Q_
V ` ��
Date Appli4ant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER f
(This section need not be completed If the work Involved by MAIL /
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS C� as na's
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL.NO2
so as to become subject to the Workers'Compensation Laws. DISHWASHERta 00 CONTRACTOR 1 k 77,
Date Applicant CLOTHES WASHER ADDRESS s NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY -04 yn a-3 TEL. NO
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE r// LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DI TRICT NO PR SSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is In full force and effect.
eect. 5 PER SYSTEM FINAL n Q ALIDATION
License Number Lic. Cie I�1�G� DATE /�y�6�/
C�S BY AL 47X0 ""W C
Contractor Date O
❑ V
I am exempt under Sec. W
B.AP.C. for this reason Plan check fee ® cri
Oe
Date: �
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE 1130 lop
Plan check applicant
SINGLE FAMILY �p
HOME OWNER-BUILDER DECLARATION Name tr
teCTc
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address �LoWJ
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the il�!
structure is not intended or offered for sale (Section ® T01 100
7044, Business and Professions Code).
UCS(
CONSTRUCTION LENDING AGENCY ol
I hereby affirm that there is a construction lending agency for MAI Am
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address 1 4. IMS
I certif read this application and state that the
e informatio s correct. I agree to comply with all County
ordinances and ft State Ia eguloting Plumbing, and hereby
orize repressentati s this County to enter upon the
obov entioned property or inspection purposes.
i � SEE REVERSE FOR EXPLANATORY LANGUAGE
�f ure of Per tt�e Date Y