HomeMy Public PortalAbout5031 ALESSANDRO AVE_Plumbing__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
insure or a certificate of Workers Compensation Insurance CE 817(REV 10/81)
or a certified copy thereof (Sec 3800 Lob
�C ) L ' COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy NoJR6 _7 company cYJ!al D `//Zy,
❑ Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
5PCertified copy is filed with the county building inspec ADDRESS
tion de artment /� NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date L Applicant ( WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars($100)or less ) LAVATORY MAIL ADDRESS �O 3
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CITY _ TEL NO
so as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR A
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making this Certificate of
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth CITY TEL NO
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM r 7L' �//� n 7�
deemed revoked WATER HEATER STATE
NO / 7�0 lJ CLASS v v
LICENSED CONTRACTORS DECLARATION DISTRICT NO OCESSEB BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS r-
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER `5 G >-
and Professions Code and my license is in full force and effect S PER SYSTEM FINAC1
[/ �ry DATE L ��� VALIDATION U
License Number `S Lic Class G-ay
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^'Y - /� _ FINAL
Contractorr iu 'wi�LO Date — BY
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I am exempt under Sec H
B&P C for this reason Plan check fee vO Z
Date
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEEj sc�
Plan check applicant
SINGLE FAMILY --g Q 3 3 Q A
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s License C 9'o o o o * 5
Law for the following reason (Section 7031 5 Business and Address , I
Professions Code) CityTel No5���� 2 °�°
1650
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I as owner of the property will do the work and the 00 0 0 1 16 5 �
structureis not intended or offered for sale (Section , �I t00-84 O r 8
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 roperty for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee - ` Dater - _ E