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Home My Public Portal About9822 WINDSOR LN_Plumbing__ WORKERS'COMPENSATION DECLARATIONAPPLICATION FOR PLUMBING; PERMIT I Fiereby affirm that I have a certificate of consent to self 1 20-0026 DPW 6/87 insure, or a certificate of Workers'Compensation Insurance, 76AS67A lul 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. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING p 10"Certified copy is filed with the county building inspec- i ADDRESS tJ d part a NUM ER' FIXTURE OR ITEM ® FEE ,t`� LOCALITY Date Appligant r WATER CLOSET V NEAREST ye CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB D� CROSS S7. COMPENSATION INSURANCE "�' OWNER SHOWER r (This section need not be completed If the work Involved by _ the permit is for one hundred dollars($100)or less.) I LAVATORYMAIL ADDRESS I certify that in the performance of the work for which this ' permit is issued,I shall not employ any person in any manner ' SINK O CITY TEL.NO. — so as to become subject to the Workers'Compensation Laws. DISHWASHER0 CONTRACTOR , v Date Applicant CLOTHES WASHER ADDRESS _ (� NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL.NO with comply with such provisions or this permit shall be STATE �/'� LIC. deemed revoked. WATER HEATER it) 00 LICENSE NO. o(JUJZ&V CLASS LICENSED CONTRACTORS DECLARATION7RIQ NO PR ED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS d C�/11-LAO (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL°� I�� VALIDATION DATE License Number Lic. Class 8 FINAL Contractor („-"r Date BY 0 ❑ I am exempt under Sec. W B.BP.C. for this reason ® Cn Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION Name ACCT.A I hereby affirm that I am exempt from the Contractor's License Address ns Law for the following reason (Section 7031.5, Business and ? to ProfessioCode): City - Tel. No. ❑ I, as owner of the property, will do the work and the 1 ZTEH structure is not intended or offered for sale (Section ® TOTAL 90©CDC 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY i CECK 90.0 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued "' ° (Sec. 3097, Civ. C.). Lender's Name 00-06011ai 7/ 6/89 Lender's Address 5W 1 AH110005 I cert' a ave ad this ap lication and state that the a ve information is rrect. I r to comply with all County ' o inances and St laws r gula ng Plumbing, and hereby out ' e reprelentatives this ounty to enter upon the , above-m tioned property for ins' ' n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE re of Permit Date i