HomeMy Public PortalAbout5037 ALESSANDRO AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
t by affirm that (..hove a certificate of consent to self 76A667A
10 7 insr .. orV crrtif' f Workers' Compensation Insurance, CE 817(REV. 10/81) ��JJ
or 4 certified co th ',.of (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished.❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING L A46
Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM a FEE
LOCALITY
Date Applicant / WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB
CROSS ST. 3,4
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. MAIL
P ( ) LAVATORY ADDRESS
I certify that in the performance of the work for which this �/
9'
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO. �,r
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so as to become subject to the Work rs Compensation aws. 11 DISHWASHER GGG��4iJJJ
CONTRACTOR
Dat e%Sl Applicant �m , / 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.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ^OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS /t
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER �/
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
VAI ATION y
License Number Lic. Class DATE —AA-41
FINAL 0
Contractor Date BY
❑ 0 I am exempt under Sec.
B.&P.C. for this reason U
Plan check fee ► CL,
Date: PLUMBING PERMIT ISSUING FEE$ ;281 6 8 A Z
Signature
TOTAL FEE # o o"o o,o 5
Plan check applicant
SINGLE FAMILY ) ;° ° 2 a 5,0
HOME OWNER-BUILDER DECLARATION Name o 0 0 2 5 v
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
Pro ssions Code): City Tel. No. 0,2 2 a 8 7
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
,
F7044, 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
abe- ntioned pronsctfor inspect n puorposes.
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SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Dote