HomeMy WebLinkAbout1370 VALLEY VISTA DR (17) WORKERS'COMPENSATION DECLARATION � �pO�
i hereby,affirm ihai I have a certificale of consenf to self in- 7���A PW a�B7 I�PPLICATlON FOR PI.UMBING PERMIT
wre,or a certificote of Workars"Compensation�nsurance,or o �E 817(REV.8/86) /
certified mpy thareof(Sec.3800,Lab.C.i _ �"� ',
Policy No.11ICCIo��}77�o�npany G�/�li�lC��t��[ C�UNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
� Certified copy is here6y furnished.
FOR APPLICANT TO FlLL IN(PKINT OR TYGE; BUILDING
� Certified copy is filed with 1he county 6uilding inspection ADDRE55 37(f � �j- �..
depariment. / ��� NUMBER FIXTURE OR ITEM � FEE ��A`TY
.�-�,C{O� .,U /� J
ppte['�Applicant/L�,���G. � WATERClOSEf(T61LET) NEAREST �J �
� GareUu.y Gv�r �y..c �
CERTffICATE OF EXEMPTION FROM WORKERS' eniN rua CROSS Sr.
COMPENSATION INSURANCE SNOWER OwNER
(This soction�road not bo tomploMad iF the work inrolv�d 6y ��L
�c r �
fhe permif ia fer one hund■ed dollar�(3T00)or Iesa.} LAVATORY ADDRE55
I certify that in Ihe performonce of fhe work for which this pet- SINK ('-
mit is issued,1 shofl not employ any person in any manner so �T7f/L (/� CtiV ieL NO.
as to beeome subjen ro the Workers'Compensation Laws. pi�WqSHER �
CONTRACTOR
Date Applicont CLO7HE5 WASHER �^r } � �
ADDRFSS
�TQ APPtICANi:!f,ofzer moking ikis Certificote of Ex- ��i,
� �on,yov shovkF6ecome su6jxt to ihe Worken'Compen- SWIMMING POOL RECEPTOR 2 f 1 �
��� u 6 TEL.NO.
SafiOn p�avi51on5 Of tfte labof CeC1B,y0u musi fortMlWItF1[omp- �pWN SPRINNIER SVSTEM y'*v .����it �
ly with such provisions or this permir shall be deemed revok- STATE lIC �T �
ed. / WATER HEATER . � n�'1 LKENSE N '7UQY6 C�.455 . i
LICENSED CONTRACTORS DECLARATION V�� DISTRIC7 NO. PROCESSE�BY �
i hereb affirm 1ha1 l am�licensed under GAS SYSTEM OUTLESS b �
y provisions of Chapter
9(commenting with$ection 7W0)of Division 3 ot the Business OUTtEfS OVER '
ond Profassions Code,and my license is in full force and ef- 5 PER Sr57Enn fINAL y �
fect. /� /�� �/ , � oATE 7 �� f VALI ATION a
License Nvmber�.7�7��� lic Elou� r V �
Contratfot���`r�lt ��,,.� FINAL � �
Date Z � 81' �,Qjt� p
� 1 am exempr under Sec. � � t � U �
B.&P.C.for this reason �'
Ptan check fee � � �
DO�e' ' PLUMBING PERMIT ISSU�NG FEE$ `o� �
SignaWre
TOTAI fEE � (�
SINGLE FAMILY Plan cAeck a licant
HOME OWNER-BUILDER DECtARATION PP
� I b^•=by offirm fhot I am azempr frvm rhe Cantractor's License Name
� L� x the following reason(Section 7Q3].5, Businass and � c c w 7 C f�
P.�ssions Code�: FWCIrB95 �
�a • e e a 5
� I,as owner of the property, will do�he work and the City Tal.No.
strutlure is not i�tended or offered for sak(Section 7044, , f • r(��ti��,
Business and Professions Code).
CONSTRUCTION IEN�ING AGENCY � � � �`�'`"' � �
f hereby affirm.tho�ihere is a construcfion lending ogency for � - � 1 �C—���:
the performance of ihe work for which ihis permit is issued .
�Sec.3097,Civ.C.).
f tender's Noma
� lender's Address
I certify ihot 1 have read this applitaHon and state that�he
above in#wmation is correct I aqree to comply with all Counry �
ordmances and State laws re9ulating Plumbing,ond here6y
authprize represeMatives of fhis Couniy�o enter upon the
�obove- en�ioned property fo�inspettion purposes.
���^��.�`� ��_g_ �. SEE REVERSE FOR EXPLANATORY LANGUAGE
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