HomeMy Public PortalAbout9816 WINDSOR LN_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I,p;ereby affirm that I have a certificate of consent to self 20-ob26 DPW 6/B7
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 p ,
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
rtm NUM R FIXTURE OR ITE @ FEE L1
Certified copy is filed with the county building inspec- M
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LOCALITY
Date Appligant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB
CROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be completed If the work Involved by SHOWER
MAIL
the permit Is for one hundred dollars($100)or less.) LAVATORY ADDRESS 17t -1
I certify that in the performance of the work for which this
permit is Issued,I shall not employ any person In any manner SINK CITY TEL.NO.
so as to become subject to the Workers'Compensation Laws, DISHWASHERr
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption,' you should become subject to the Workers' CITYTEL.NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions. or this permit shall be STATE LIC. 2
deemed revoked. WATER HEATER 1,LICENSE NO. CLASS Z J
LICENSED CONTRACTORS DECLARATION 0 DISTRICTrg RO ED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM _ OUTLETS 5;
U y
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER c—�� (((JJJ
and Professions Code, nd my license is in full force�an�d effect. 5 PER SYSTEM �� FINAL • L �� VALIDATION
-�_—`-k DATE Z
License Numb Lic. Class
FINAL
Contractor Date
g BY v O
❑ 1 am exempt under Sec. W
B.&P.C. for this reason ® en
Plan check fee �
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
_i
Plan check applicant
SINGLE FAMILY q/�
HOME OWNER-BUILDER DECLARATION Name - - ACCTu0
I hereby affirm that I am exempt from the Contractor's License Address 3307 90.0Law for the following reason (Section 7031.5, Business and 1
Professions Code): i City Tel. No. 1 ITEMS
❑ I, as owner of the property, will do the work and they
structure is not intended or offered for sale (Section I , TOTAL 90 n 013
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY offGr 901p100
I hereby affirm that there is a construction lending agency for sa M
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
OOOO°DIID1
Lender's Name � , 9/ 6/89pt+�q
Lender's A i 1 6i7ed1o06
I gc ' y that I have ad this application and state that the
a ve information is correct.fthis
e to comply with all County
ordi ccs and State laws r 'ng Plumbing, and hereby
u oriz epresentatives o ounty to enter upon the
above iz n s property f 'AM
' rpoter
SEE REVERSE FOR EXPLANATORY LANGUAGE
-Co-
Signature of Permittee Date