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Home My Public Portal About5342 ALESSANDRO AVE_Plumbing__ +WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT 76A66 At 6 DPW 4/87 • 9 hereby affirrp that 1 have a certificate of consent to self in- 76A667A sure,or o'certificate of Workers'Compensation Insurance,ora CE 817(REV. 8/86) certified copy thereof(Sec. 3800, Lab. C.) `fl ��QBL� � COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No.. LCompany. Certified copy is hereby furnished.. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspection ADDRESS 53� Ar4OAD Aye" NUMBER FIXTURE OR ITEM' LOCALITY department. @ FEE WATER CLOSET(TOILET) ]"PLC CA Date P Applicant NEAREST CERTIFICATE OF EXEMPTION FROM OR_KERS' 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 J I certify that in the performance of the work for which this per- Q mit is issued, I shall not employ any person in any manner so SINK - CITY TEL. NO. `�✓ as to become subject to the Workers' Compensation Laws. DISHWASHER p CONTRACTOR i ([MDOG"c U .�'0 Date Applicant._ CLOTHES WASHER NOTICE TO APPLICANT: If, after making this.Certificate of Ex- ADDRESS al L!/. G QAC SWIMMING POOL RECEPTOR emption, you should become subject to the Workers'Compen- sation provisions of the Labor Code, you must forthwith comp- L EM /14 T CITY �V��A /L EL NO. �pn S7 ly with such provisions or this permit shall be deemed revok- UJ V STATE (� p� �T LIC. ed. WATER HEATER LICENSE NO. / I5p J CLASS �—1 LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM ' OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER fed Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL V VALID ION DATE 0 License Number %022 Lic. Class� U FINA Contractor Date BY 0 ❑ I am exemp nder Sec. LU 9L B.&P.C. for this reason , U) • Plan check fee Date: PLUMBING PERMIT ISSUING FEE $ Signature TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and Professions Code): Address , a I, as owner of the property, will do the work and the City Tel. No. ACCT 4 rn �( structure is not intended or offered for sale(Section 7044, 0-7 -i-f Business and Professions Code). {, ITEMS CONSTRUCTION LENDING AGENCY _ �-�¢ I hereby affirm that there is a construction lending agency for 'I I�)A 22-51D the performance of the work for which this permit'is issuedC�;�1� y.50 (Sec. 3097, Civ.'C.). CHANGE o Oct Lender's Name. Lender's Address t I certify that I helve read this application and state that the ► % j a c above information is correct. I agree to comply with all County [iii t1 _ A1,1_ i•_ ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-menti Heel pro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permi 1 Date .