HomeMy Public PortalAbout4908 ALESSANDRO AVE_Plumbing__ ION
WORKER'S I have
a certificate
of consent to 76A666DPW9/89 APPLICATION FOR PLUMBING PERMIT
76A667A
I hereby affirm that I have a certificate of consent to self insure,
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.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING � -p I r(_!ss 5
❑ Certified copy is filed with the county building inspection ADDRESS -1 o ("t
department. NUMBER FIXTURE OR ITEM Q FEE
Date Applicant WATER CLOSET / O� �� LOCALITY-Y_ Q� �-I Y e,4- "TO/Lc� NEAREST � L'
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. fJs f}
COMPENSATION INSURANCE BATH TUB ASSESSOR
(This section need not be completed if the work involved by the SHOWER MAP BOOK %� PAGE�T PARCEL&
permit is for one hundred dollars($100)or less.) i LAVATORY �6 OWNER' o� sC If „p Q Z>�.A ^S Z_
.1 certify that in the performance of the work for which this permit /1 1/ 1�1I�-+'�
is issued, I shall not employ any person in any manner so as to MAIL
� SINK ADDRESS "o A l LSS/Tr'1i�a 5 i
become subject to the Workers'Compensation Laws.
DISWASHER CITY P l TEL.NO..7L� ?
?-7. 4 ft
Date Applicant ` CLOTHES WASHER �J 6 d CONTRACTOR 3 `o
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption,you should become subject to the Workers' Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO.
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER
(commencing with Section 7000 of Division 3 of the Business and STATE LIC.
( g ) LICENSE NO. CLASS
Professions Code, and my license is in full force and effect. GAS SYSTEM ! OUTLETS J✓ V
OUTLETS OVER DISTRICT NO. PROCESSED BY Q
5 PER SYSTEMp�(yam- ��
License Number Lic.Class C/O))) V
FINAL /1 /Vk .DA' ION W
DATE ✓"� LU
Contractor DateLJ-I7 115.CS-0
INAL 1 ;
El4 ON:S Z
I am exempt under Sec. BY
B.&P.C.for this reason �® f OT AL 115 = 65
Plan check fee '
Date: GN115.e 63
PLUMBING PERMIT ISSUING FEE$ !_:
jy`(3_E
Signature
❑ TOTAL FEE J
SINGLE FAMILY Plan check applicant 00010-000 1 5
HOME OWNER-BUILDER DECLARATION Name _-4'1 i 4r, •-�,5-
1 hereby affirm that I am exempt from the Contractor's License Law 7._!L6
1 :E�:
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
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.)
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 pJ_thi;County to enter upon the above-mentioned
property fo inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
1 - -
Sf -u56 Qtee Date