HomeMy Public PortalAbout5019 ALESSANDRO AVE_Plumbing__ ION
WORKER'S I have
a certificate
of
20-0026 DPW 9/89 APPLICATION FOR PLUMBING PERMIT
76A667A
I hereby affirm that I have a certificate of coc!sent to self insure, - -
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.�',
)
�co
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
Policy No. �bCertifiepybyrnished. BUILDING C
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy is filed with the county building inspection
department. ( NUMBER FIXTURE OR ITEM Q FEE LOCALITY
Date Applicant WATER CLOSETNEAREST
CERTIFICA OF EXEMPTI N FROM WORKERS' BATH TUB
CROSS'ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the
SHOWER MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) LAVATORY OWNER / O / !ti
I certify that in the performance of the work for which this permit MAIL 7 Z
is issued, I shall not employ any person in any manner so as to SINK ADDRESS
become subject to the Workers'Compensation Laws. /
DISWASHER CITY TEL.NO.
Date Applicant CLOTHES WASHER CONTRACTOR � \J ,
NOTICE TO APPLICANT: If, after makingthis Certificate of Iv w
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS It,/ /fuJ/t�
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM ` rte!
LICENSED CONTRACTORS DECLARATION CITY �� TEL.NO.
0.
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER
(commencing with Section 7000) of Division 3 of the Business and STATE LIC. o
Professions Code, and my license is in full force and effect.
GAS SYSTEM OUTLETS LICENSE NO. CLASS , 0
OUTLETS OVER DISTRICT NO. PROCESSED BY O
/� 5 PER SYSTEM
License Number Lic.Class J,
` FINAL _ /7..-�'Z
DATE G/ W
VALIDATION
Contractor lDate 01 a(n
❑ I am exempt under Sec. FINBY AL �`'4'�
BAP.C.for this reason
Date: Plan check fee
Signature PLUMBING PERMIT ISSUING FEE$
❑ TOTAL FEE
Plan check applicant
SINGLE FAMILY r�
HOME OWNER-BUILDER DECLARATION Name
ACCT e'ff
I hereby affirm that I am exempt from the Contractor's License Law i15 s•"E,_;I�
for the following reason (Section 7031.5, Business and Professions Address
Code): T
❑ City Tel, No. 1 i T EME3
I, as owner of the property,will do the work and the structure 1"jT 5 m5
is not intended or offered for sale (Section 7044, Business ;s€; ilW __a __e
and Professions Code). ' fK L— 50
CONSTRUCTION LENDING AGENCY CHANGE z I j1
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.) €U tU—U_!U 1 1 C!i t:
Lender's Name _33106 1 AN 8:4�
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
property for inspection urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE