HomeMy Public PortalAbout9415 WOODRUFF AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I havL* a certificate of consent to self 20-0026 DPW 6/87
insure, or a teriificate of Workers'Compensation Insurance, 7GA667A lul
or a.certified copy there54-(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished. BUILDING
ElADDRESS APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS V
Certified copy is filed with the county building inspec- NUMBER FIXTURE OR ITEM ® FEE
tion department. LOCALITY'
we,1 'to,/
Date Appligont WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER /_A
(This section need not be completed If the work Involved by SHOWER I
'
MAIL;
the permit is for one hundred dollars($Lal))or loss.) LAVATORY I ADDRESS
I certify that in the performance of the work for which this -a
permit is issued,I shall not employ any person in any manner SINK G CITY TEL.NO.
so as to become subject to the Workers'Compensation Laws.
DISHWASHER CONTRACTOR
Ipplican� ' � CLOTHES WASHER ADDRES �/ R/8
NOTICE TO APPLICANT: If, after making thi ertificate of SWIMMING POOL RECEPTOR /
Exemption, you should become subject to the Workers' �v ���
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM TY TEL.
with comply with such provisions or this permit shall be STATE s LIC.
deemed revoked. WATER HEATER LICENSE CLASS
LICENSED CONTRACTORS DECLARATIONDISTRICT O P D BY
I hereby affirm that I am licensed under provisions of Chapter 9
GAS SYSTEM / OUTLETS A
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,OdSec.'
ense is in full force and eff ct. 5 SYSTEM FINAL a VALI ATION
o / DATE i
License Nu 9 QLic. Class C� � FINAL � U
Contract ate BY 1
I am exempt u
IBJ
BAP.C. for This reason__ no
Plan check fee
/ ® `
PLUMBING PERMIT ISSUING FEE$
VaturHOME
TOTAL FEEPlan check applicant "H07 4`°ill;SINGLE OWNER-BUILDER DECLARATION Name iTE�I''
I hereby affirm that I am exempt from the Contractor's License Address �TOTAL 43.00
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. 413.10
❑ I, as owner of the property, will do the work and the ® twN (�ti oGo
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 3/13/K
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued 9426 1 AN11311
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
dinances d State law �tlngPllnumbing, and hereby
i ret ental' tenter upon the
ave-menti a rposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
I
Sig ature of Frertnittrate