HomeMy WebLinkAboutNo Permit Number (2195)WO RKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, or
a certified
copy thereof (Sec. 3800 ab... C.) `
Polly N6.• t� ���55 CompanyJ'L15 74N/s
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection
tm epar
Date APplicarbAFEW-4 V OF.r—�,�r.,-,�-r�rr�r G
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved
by the permit is for one hundred dollars ($100) or leas.)
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under pmvisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect. Q
License Number '^ / � Lic. Class _ q�
13 1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code).
Lic. or Reg. No. Date
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code):
❑ 1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project
(Section 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
1 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
Lender's Address
I certify that I have read this application and state that the
above informatio s correct. I agree t ply with all County
ordinance p S to la mg P robing, andhereby
au
' re �e taiive this Co y to enter upon the
a6 -merit' ed pro t Fo ction purposes.
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Signature of Permittee C,,Vate
.R$17(a-ao, APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
NUMBER
FIXTURE OR ITEM
!
FEE
WATER CLOSET
1
Z
BATH TUB
1
Z
SHOWER
t
J;
LAVATORY
SINK
/
DISHWASHER
CLOTHES WASHER
SWIMMING POOL RECEPTOR
LAWN SPRINKLER SYSTEM
WATER HEATER
GAS SYSTEM lj. OUTLETS
IOUTLETS
5 PER SYSTTEMR I
Plan check fee
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
Plan check applicant
Name
Address
City Tel. No.
SEE REVERSE FOR EXPLANATORY LANGUAGE
BUILDING AND SAFETY
BUILDING
ADDRESS /33o S. XkD1
LOCALITY V-11 A.rn 11
a
CROSS ST.
OWNER
PRESLEY CO.
MAIL
46LKJ UANIFU= UhiVL
ADDRESS
NEWPORT BEACH, CA
CITY
TEL. NO.
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CONTRACTOR
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ADDRESS
SAFEWAY PLUMBING & HEATING INC.
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