HomeMy Public PortalAbout4821 ALESSANDRO AVE_Plumbing__ y WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT L
I hereby affirm that I have a certificate of consent to self 20 OQ26 DPW 6/87
insure or a certificate of Workers Compensation Insurance 76A667A
or si certified copy
��Sec 3800 Lab C COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy No ompany
F .
Certified copy is hereby furnished
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec ADDRESS
tion department NUMBER FIXTURE OR ITEM @FEE LOCALITY �
Dole 5'Z Appli n WATER CLOSET �9 0 NEAREST
CERTIFICATE OF EXE FROM WORKERSFIR M WORKERS ` BATH TUB CROSS ST U G`
COMPENS ON INSURANCE SHOWER r�/ OWNER t
(This section need not be completed if the work Involved by aJ MAIL
the permit is for one hundred dollars ($100)or less ) LAVATORY q Q ADDRESS �d
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CITY 12 TEL NO
so as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR
'4J LJ
Date Applicant CLOTHES WASHER ADDRESS n
NOTICE TO APPLICANT If after making this Certificate of SWIMMING POOL RECEPTOR
Exemption you should become subject to the Workers CITY TEL NO
Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS D D r�
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER O
and Professions Code and my/license is in full force and effect 5 PER SYSTEM FINAL '�C pjL VALIDATION d
License Numb J Lif&JA
Class � DATE U
t �
FINAL O
Contractor
❑ I am exempt under Sec U
B 8P C for this reason o" 0-1
-Z� 2 Plan check fee D �r Z
to PLUMBING PERMIT ISSUING FEE$
Signal ur TOTAL FEE V 11 a'
SINGLE FAMILY
F _
Plan check applicant
(J�
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 5 Business and Address
Professions Code) City Tel No
❑ I as owner of the property will do the work and the
structure is not intended or offered for sale (Section ® v
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 )
Lender s Name
Lender s Address a
I certify that I have read this application and state that the
above information is correct I agree to comply with all County poll
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
4
Signature of Permittee Date