The URL can be used to link to this page

Home My Public Portal About4814 ALESSANDRO AVE_Plumbing__ WORKER'S COMPENSATION DECLARATION 6DPW 9189 APPLICATION FOR PLUMBING PERMIT 76A66 I hereby affirm that I have a certificate of consent to self insure, 76A667A or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab.C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. Policy No! Company Certified copy is hereby furnished.❑- BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS �• �� a�' ��/��J�L.'�J Certified copy is filed with the county building inspection department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET CNEAREST ROSS ST. L CERTIFICATE OF EXEMPTION FROM WORKERS' © BATH TUB COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK ffyy�� PAGE PARCEL permit is for one hundred dollars($100)or less.) LAVATORYOWNER Q t.- I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to SINK MAIL ADDRESS become subject to the Workers' Compensation Laws. DISWASHER CITY TEL.NO. Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR 6ry provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. A611LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER (commencing with Section 7000 of Division 3 of the Business and STATE LIC. O ( 9 ) LICENSE NO. CLASS Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS / V DISTRICT NO. PROCESSED BY OUTLETS OVER Ir 5 PER SYSTEM /� a �y� O , License Number Lic.Class FINAL VALIDATION a DATE y,I �...rQ . Contractor Date ;..`•�-'•:i =4 fn ❑ I am exempt under Sec. gy AL _Z B.&P.C.for this reason w s Plan check fee _ Date: PLUMBING PERMIT ISSUING FEE$ " Signature i`e,MP t ; _ <c TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law `,.`s (,"i— ( I,) =i=i k. yaF for the following reason (Section 7031.5, Business and Professions Address Code): City Tel. No. I, as owner of the property,will do the work and the structure IN is not intended or offered for sale (Section 7044, Business and Professions Code). ' CONSTRUCTION LENDING AGENCY 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.) 1 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 ordinances / and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned proper for insp ion purposes; SEE REVERSE FOR EXPLANATORY LANGUAGE 19 Signature of-Permittee/ D to