HomeMy Public PortalAbout4809 ALESSANDRO AVE_Plumbing__ ,^WORKERS' COMPENSATION DECLARATION �-
I K r:e ctffirin that I have a certificate of consent to self in- 26A667 DPW 4/87 APPLICATION FOR PLUMBING PERMIT
76A667A'
54:re,or a ceelificate of Workers'Compensation Insurance,ora CE 817(REV. 8/86)
certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING �O
Certified copy is'filed with the county building inspection ADDRESS �j^ p7
department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date Applicant f WATER CLOSET(TOILET) 6,60
NEAREST
BATH TUBCROSS ST. `fj[�
CERTIFICATE OF EXEMPTION FROM WORKERS' �' S
COMPENSATION INSURANCE OWNER �Aj ���
SHOWER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100) or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK
mit is issued, I sha I not employ any person in any manner so CITY TEL. NO.
as.to becam s ct the Workers'Compensation Laws. DISHWASHER
CONTRACTOR -�
Date Applicant CLOTHES WASHER
NOTICE TO PP ANT: If, after making this Certificate of Ex-
emption,y u sh u1d become subject to the Workers'Compen- SWIMMING POOL RECEPTOR
sation pro isions of the L.
Code, you must forthwith comp- CITY TEL. NO.
P Y P LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall.be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICIP0j PROCE
�� D BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS �(r
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM• FINAL IDATION
fect. DATE
O
License Number Lic. Class U
FINA �
Contractor Date BY O
I am exempt under Sec. Uj
B.BP.C. for this reason ► g
Plan checkz 0 5 5
fee .2,A
Date: PLUMBING PERMIT ISSUING FEE$ # 0 0 0 0 0 5
Signature
TOTAL FEE Vill
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant
1 hereby affirm that I am exempt from the Contractor's License Name 4 0.5 0�
Law for the following reason (Section 7031.5, Business and:
Professions Code): Address 0 8 2 9-8 8
I, as owner of the property, will do the work and the City: Tel. No.
structure is not intended or offered for.sole(Section 7044,
Business and Professions Code). ,
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performdnce 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 ainfor , o is correct. I agree to comply with all Countyordina tate laws regulating Plumbing, and hereby
outhorentatives of this County to enter upon the
above- d property for inspection purposes.
Zg SEE REVERSE.FOR'EXPLANATORY LANGUAGE
Signci a of Permittee Date
9�1