HomeMy Public PortalAbout5332 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 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy Nc000291 090ompany CNA
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 5332 a l e s andr o
❑ Certified copy is filed with the u uilding n ADDRESS
tion department NUMBER FIXTURE OR ITEM @ FEE LOCALITY
8/15/86 WATER CLOSET Temple City
Date Appl i NEAREST
CERTIFICATE OF EXE P N FROM RI RS BATH TUB CROSS ST :
COMPENS ION 1NSURAN E OWNER
SHOWER
(This section need not b completed if the work in of d by MAIL
the permit is for one h ndred dollars (;100)or le LAVATORY ADDRESS 5332 Ale sandro
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 N0285-6362
so as to become subject to the Workers Compensation Laws Temple City
DISHWASHER CONTRACT
R`'at Taylor & Sons Plumb
Date Applicant CLOTHES WASHER ADDRESS 8402 Katella Ave
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 LAWN SPRINKLER SYSTEM CITY Stanton
TEL NC$2 8-0 5 5 O
with comply with such provisions or this permit shall be LSTATE ICENSE NO 136616 LIC C36
deemed revoked 1 WATER HEATER 0 600
LICENSED CONTRACTORS DECLARATION DISTRICT NO ROCESSED RY
I hereby affirm that I am licensed under provisl f Chapter 9 GAS SYSTEM OUTLETS ��` O Q
i (l �,
(commencing with Section 7000) of Divisi 3 of a Business OUTLETS OVER
IL
and Professions de and my license i or and effect 5 PER SYSTEM FINAL
136616 C36 DATE VALIDATION O
License Num is C
FI O
Contra to B ~
�J
❑ I*ZXmpt u r e 9L
1/f
B&P C for this reason
Plan check fee 10.
Date
PLUMBING PERMIT ISSUING FEE$ 10 50
Signature
TOTAL FEE 16 5 0
Plan check applicant
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s License Address
Law for the following reason (Section 7031 5 Businesf and
Professions Code) City Tel No
❑ I as owner of the property will do the work and the
structure is not intended or offered for sale (Section ® ;2 5 3 5.6 A
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY # o a o o 0 5
1 hereby affirm that there is a construction lending agency for "
the performance of the work for which this permit is issued 1 ° ° 1 6,50
(Sec 3097 Civ C ) _
16.50,5)
Lender s Name 0 093-86
Lender s Address
I
I certify that I have read this application and state that the
above i rmation is correct 1 a r o omply with all County
ordin ce and State laws re lating Iumbing and hereby I
auth raze representatives this Co my to enter upon the
abo a tioned prop or insp tion purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
8/15/86
Ig re o itt Date