HomeMy Public PortalAbout4929 ALESSANDRO AVE_Plumbing__ DECLARATI
• WORKER'S I COMPENSATION
ate 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 thedf(Sec.3800,Lab. C.)
Policy No. Company
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
1:1 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Q�� A A L ' �Aw
El Certified copy is filed with the county building inspection ADDRESS l r JOO-
department. NUMBER FIXTURE OR ITEM
@ FEE LOCALITY
ate Applicant PP / WATER CLOSET NEAREST
BATH TUB
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the SHOWER MAP BOOK 017 GE31-33, PARCEL
permit is for one hundred dollars($100)or less.) LAVATORY L OWNER I�
I certify that in the performance of the work for which this permit L
is issued, I shall not employ any person in any manner so as toMAIL WEAPA • M �
e
become subject to the Workers' Compensation Laws. SINK ADDRESS /Q t/`
DISWASHER CITYgo
TEL.NO#73
Date Applicant CLOTHES WASHER CONTRACTOR
NOTI E TO APPLICANT: If, in hi Certificate of
Exemption,you should become subje o the o '6 ation SWIMMING POOL RECEPTOR
provisions of the Labor Code, yo must fort i such ADDRESS
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO.
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER O O
(commencing with Section 7000) of Division 3 of the Business and STATE LIC.
Professions Code,and my license is in full force and effect.
GAS SYSTEM OUTLETS LICENSE NO. CLASS 0
OUTLETS OVER STS((`\J T PR ESSED BY cc
5 PER SYSTEM Q
License Number Lic.Class r V
FINAL Q
Contractor Date DATE/1 Z.7 v 06�1/11CION a
❑
I FINAL Z
am exempt under Sec. _ BY %"
B.&P.C.for this reason
Date:
Plan check fee ,
Signature
PLUMBING PERMIT ISSUING FEE$
❑ TOTAL FEE
SINGLE FAMILY Plan check applicant
e
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 Professions Address
Code): »r. n I_I).
EJ 1, City Tel. No. t:•t
i•_tJ 4�M t
I, as owner of the property,will do the work and the structure I S
:_t
is not intended or offered for sale (Section 7044, Business
and Professions Code). , TOTAL 4,.1 - 00
CONSTRUCTION LENDING AGENCY g,H i„.it i .'• _'
I hereby affirm that there is a construction lending agency for the p
performance of the work for which this permit is issued (Sec. 3097, CHA1,11_E a0?,
Civ. C.)
Lender's Name L' U
¢7qSNCP� i •il, _SJ 1E 10/22L
I r.
11
AC—Lender's Address I _gji"
I certify that I have read this application and state that the above /(/ `�'�r�✓{ ,
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
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE