HomeMy Public PortalAbout9813 WINDSOR LN_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT f�
I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 '� I
insure, or a certificate of Workers'Compensation Insurance, 76A667A jll
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) ADDRESS
Certified copy is filed with the county building inspec-
ts e ort a dNUMBER FIXTURE OR ITEM @ FEEE LOCALITY/01-
.y
Date gppli4ont , / , WATER CLOSET V NEAREST f
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 010 CROSS ST. U 7
COMPENSATION INSURANCE SHOWER v OWNER �• 7
(This section need not be completed if the work involved by MAIL �--+
the permit Is for one hundred dollars($100)or loss.) LAVATORY Do ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK 11 00 CITY TEL.NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR
Date Applicant CLOTHES WASHER9 ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CIT r TEL.NO
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM a
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO.0 4 3 CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ESS D BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS O
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, nd my license is in full force and effect. 5 PER SYSTEM FINAVALIDATION d C
DATELI]-J24/
License Number L1c. Class C-3(10 ( C:
FINAL
Contractor a Date Lu BY � lC�,
❑ 1 am exempt under Sec.
B.BP.C. for this reason
Plan check fee v
Date: 6
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE 1 Q61 Q
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name �4GTo�
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and �7 toy(
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the I10
structure is not intended or offered for sale (Section - ® I ,,nn �,
`
7044, Business and Professions Code). )t j' "r "
CONSTRUCTION LENDING AGENCY :"::Fi gao�D
1 hereby affirm that there is a construction lending agency for n!
the performance of the work for which this permit is issued ;; - ,QTI
(Sec. 3097, Civ. C.).
Lender's Name C ut 91 9/ 6/89
Lender's Address 1 MUM
I certify tW&$-4-l5aread this application and state that the
abo n ormatiorris correct. I a ee to comply with all County
o inances and State laws re I ting Plumbing, and hereby
au ze repre�enfatives of his County to enter upon the
�bove-m oned property for in e n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa ure of Permitte Date