HomeMy Public PortalAbout4815 ALESSANDRO AVE_Plumbing__ WORKERS COMPENSATION DECLARATION r" - 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
EJCertified copy is filed with the county building inspec ADDRESS
tion depart ent NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date Applicant t WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
COMPENSATION INSURANCE �� OWNER
SHOWER
(This section need not be completed if the work involved by MAIL '� J
the permit is for one hundred dollars ($100)or less ) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CITY TEL NO
so as to become s blect to the Workers Compensation Laws DISHWASHER
g"Jy CONTRACTOR
Date Applicant��f i`�/ CLOTHES WASHER
021
NOTICE TO APPLICANT If after making this Certificate of ADDRESS
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM CITY TEL NO [�
with comply with such provisions or this permit shall be STATE LIC SA f
deemed revoked WATER HEATER LICENSE NO CLA
LICENSED CONTRACTORS DECLARATION DISTRICT O ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER l-
and Professions Code and my license is in full force and effect 5 PER SYSTEM 9'
FINAL � VALIDATION OV
DATE
Se
License Number /91 Lic Class/� IM
�`✓CJ16"`�''� orf Date Q 2-( FINAL O
Contractor� BY
I am exempt under Sec H
B &P C for this reason Plan check fee
/f Date PLUMBING PERMIT ISSUING FEE$
S_ianotu_re [
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s License Address
Law for the following reason (Section 7031 5 Business and
Professions Code) City Tel No
❑ I as owner of the property will do the work and the 2 1 5 A
structure is not intended or offered for sale (Section
7044 Business and Professions Code) #to 0 o o'0 5
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for 2 0 - 2850
the performance of the work for which this permit is issued
(Sec 3097 Civ C ) o o 0 2 8 5 Q v
i
Lender s Name 0 i1r 2 7J—8 3
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 nd State jaws regulating Plumbing and hereby
authorize presentahves oft)is County to enter upon the
above tioned pro erty or spection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
11-Ignature o Permitt a Cfate