HomeMy Public PortalAbout5049 ALESSANDRO AVE_Plumbing__ I
-,WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
wl,hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Polic No. Q7 ;rpony1
❑ Certified copy is hereby furnished. U
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDADDRENG
SS
17Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM @ FEE s
/ LOCALITY
Date '20` Appligont b WATER CLOSET
Yt J/ NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' )! BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO.
so as to become subject to the Worker 'Compe tion Laws. DISHWASHER
CONTRACTOR
Date `? a-Applicant CLOTHES WASHER
ADDRESS j �j /
NOTICE TO APPLICANT: If, after making this Certificate of / / I-64C.
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY //�
Compensation provisions of the Labor Code, you must forth- �r "' TEL. NciD/gl `
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATELIC..
deemed revoked. WATER HEATER LICENSE NOCLASS
LICENSED CONTRACTORS DECLARATION X DISTRICT NO. y PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �G G
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER Q ���'�'�
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION >'
DATE
License Number /�//� Lic. Class ®'
�.
FINAL
Contractor "AIRZZ � _2A i Date �'�ET' – BY W
❑ 1 am exempt under Sec.
B.&P.C. for this reason
Plan check fee C*�
Date: PLUMBING PERMIT ISSUING FEE$
Signature t -
TOTAL FEE - y
Hit
F
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Plan check applicant
SINGLE FAMILY71
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 Address
Professions Code): City Tel. No.
❑ try?(?it "1.'?)J' =r.' f
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section ® '`' ;�j ;:� :•
7044, Business and Professions Code). W. T
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 NameO U�,/V _7�7�
Lender's Address '7'
1 certify that I have re is application and state that the
above information is c rrect. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
rz:��
ction purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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ignature of Permi ee Date