HomeMy Public PortalAbout9821 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 6/87 �j
insure, or a certificate of Workers'Compensation Insurance, 76AS67A U
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 ,f
Certified copy is filed with the county building inspec-
ts departm NUMBER FIXTURE OR ITEM
r
FEE LOCALITYAhA Of
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M. Applicant C A � 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($100)or less.) LAVATORY ADDRESS (�-. I
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner I SINK 0 CITY TEL.NO.
so as to become subject to the Workers Compensation Laws. DISHWASHER D
CONTRACTOR �J
Date Applicant ` CLOTHES WASHER 600 gDDRE55
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL. NO.,:5? ,
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATIONSTRIQ Np, PR ED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS U(Y
(commencing with Section 7000)of Division 3 of the BusinessOUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL }
�� DATE Z.�-JZ�/� ALIDATION p;
License Number c. Class C
FINAL
Contractor Date 7 BY
❑ 1 am exempt under Sec.
LLI
B.BP.C. for this reason Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature TOTAL FEE o
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License o V
Law for the following reason (Section 7031.5, Business and Address
Professions Code): City Tel. No. 3M7 90.00
❑ I, as owner of the property, will do the work and the �'
structure is not intended or offered for sale (Section �•V� �
7044, Business and Professions Code). c
CONSTRUCTION LENDING AGENCY CICICK 90.0
1 hereby affirm that there is a construction lending agency for tip
the performance of the work for which this permit is issuedc00
(Sec. 3097, Civ. C.).
i
Lender's Name 101 9/ 6/89
Lender's Add'..- 1 AHIIa05
I cert' at I have ead this application and state that the ®i
a . informat1 correct. I ee to comply with all County
rdinances and State laws r gul ting Plumbing, and hereby
a arize repre�aentatives this County to enter upon the
abov entioned property for In 1pe5JjQn purposes. p,Q SEE REVERSE FOR EXPLANATORY LANGUAGE
0 Ola
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r of Permitte Date