HomeMy Public PortalAbout5233 ALESSANDRO AVE_Plumbing__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
insure or a certificate of Workers Compensation Insurance CE 817(REV 10/81)
or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec
tion department NUMBER FIXTURE OR ITEM Q FEE ADDRESS
LOCALITY
Date Applicant 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 .S
MAIL
the permit is for one hundred dollars($100)or less) LAVATORY ADDRESS J e_
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CITY TEL NO
so as to become subject to the Workers Compensation Laws DISHWASHER
� P� N� CONTRACTOR
Date �Z` '�rt Applican �� �` CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT If afteraking is Certificate of
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth CITY TEL NO
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER LICENSE CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS D
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER .¢
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINALO.
DATE " V LI ATION O
License Number Lic Class V
FINAL
Contractor Date BY �
U
El I am exempt under Sec W
CL
B 8P C for this reason �
Date
Plan check fee 10. Z
PLUMBING PERMIT ISSUING FEE$
Signature 3W
TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER BUILDER DECLARATION Name - :996 3.8 A
I hereby affirm that I am exempt from the Contractor s License Address
Law for the following reason (Section 7031 5 Business and 0 0 0 0 0 5
Professions Code) City - Tel No
LJ I as owner of the property will do the work and the 2i0 ° 1 6 5 0
structure is not intended or offered for sale (Section ,
°
7044 Business and Professions Code) l°
� r ,° 1650P2
CONSTRUCTION LENDING AGENCY 0 3 1 3-81L
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
Lender s Address
I certify that I have read this application and state that the 00.above information is correct I agree to comply with all County
ordinances and State jaws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
above mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
gn ture f Permittee Date