HomeMy Public PortalAbout4844 ALESSANDRO AVE_Plumbing__ RKik TION DECLARATION
20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT
f{gffir a certificate of consent to self in- 76A667A
S re, 7�.(certi orkers'Compensation Insurance,ora CE 817(REV. 8/86)
certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished.
' FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
j� Certified copy is filed with the county building inspection ADDRESS (�Ss' N
JA•L department. NUMBER FIXTURE OR ITEM Ca FEE LOCALITY
caM'Pc.c� C1T
Date /.�2�—�`7 Applicant � Si� WATER CLOSET(TOILET)��y ® NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST. [_Q W a-& 7,v
COMPENSATION INSURANCE SHOWER OWNER L_Gr-a._
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY L ADDRESS
I certify that in the performance of the work for which this per-
SINK
mit is issued, I shall not employ any person in any manner so CITY C TEL. NO.
Tc�MA� i 2#Ps-y
as to become subject to the Workers'Compensation,Laws. DISHWASHER
CONTRACTOR
Date Applicant t CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- S
emptiori,you should become subject to the Workers'Compen- SWIMMING.POOL RECEPTOR CITY TEL. NO.
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE UC.
ed. ( WATER HEATER - LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION 10 DISTRICT NO. PR ESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
'anfed Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALI ATION
DATE O
License Number Lic. Class V
FI g
Contractor 'Date
I am exempt under Sec. 0
B.BP'C. for this reason g
Plan check fee m
Date: PLUMBING PERMIT ISSUING FEE $ GV z 7 9 6 3 A
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant
# o D o o 0 5
HOME OWNER-BUILDER DECLARATION pp o 4650
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and 4 5 0 v
0 0.0
Professions Code): Addressyv S'� v
1 as owner of the property, will do the work and the City ciTel. No. 24-S 0 9.21 d 8 7
structure is not intended or offered for sale(Section 7044,
Business and Professions Code).'
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constructionlending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I ceitify,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
mentioned p erty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign o Permittee Date