HomeMy Public PortalAbout4920 ALESSANDRO AVE_Plumbing__ WORKERS'COMPENSATION DECLARATIONAPPLICATION FOR PLUMBING PERMIT
I hereby, 20-0026 DPW 4/90
-affirm that 1 have a certificate of consent to self in- 76A667A
sere,or a certificate of Workers'Compensation Insurance,or a
ceO;ified''copy thereof (Sec. 3800, Lab. C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
❑ Certified copy is hereby furnished. BUILDING ?�
FOR APPLICANT TO FILL IN (PRINT OR TYPE) J
F] Certifiedcopy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date Applicant WATER CLOSET(TOILET) ��0 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' ' ,�t
BATH TUB CROSS ST.
COMPENSATION INSURANCE !' SHOWER OWNER//�
(This section need not be completed if the work involved by MAIL r'+
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK CIT�- TEL. NO.
mit is issued, I shall not employ any person in any manner so _C• /
as to become subject to the Workers' Compensation Laws. DISHWASHER
CONTRACTOR
Date. Applicant ! CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY TEL NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT-NO. PROCESSED BY
GAS SYSTEM OUTLETS
I hereby affirm that I am licensed under provisions of Chapter zwr_
9(commencing with Section 7000)of Division of the Business OU LETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
fect. HOSE BIB DATE
c
License Number Lic. Class
Contractor Date FI BY
AL ACC T a s 0
3303 0
123.90
0 1 am exempt under Sec. O a-
B.BP.C. for this reason 1 ITEMS
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ 05 , TOTAL
173 90 5
a
CHECK
123 o 9 1
Signature TOTAL FEE
SINGLE FAMILY CHANGE
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and ri000-Vs�ryy'�--��
l 4/ 9/96
Professions Code): Address (v9.
❑ I, as owner of the property, will do the work and the city Tel.
��O Ai1�=?.s
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 of this County to enter upon the
above-mentioned propert r for inspection purposes.
l� SEE REVERSE FOR EXPLANATORY LANGUAGE
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