HomeMy Public PortalAbout5538 ALESSANDRO AVE_Plumbing__ ;T10N_DE of
consent
APPLICATION FOR PLUMBING PERMIT
u cerr'ificate of consent to self in- 76A666 DPW 4/87
..?rkers'Com Compensation Insurance,ora CE 817A
P CE 617(REV. 8/86)
of (Sec. 3800„Lab. C.)
- COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Company '
Certified ;opy is,hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING; ( 71
Certified copy is filed with the county building inspection ADDRESS LJ
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
/ !
l WATER CLOSET(TOILET) LC� �+••
Date - ApplicantZ. 1z;0 NEAREST I.
CERTIFICATE
OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST. (i J
a ON INSURANCE OWNER
SHOWER -
! (This'section need not be completed if the work involved by - MAIL `
the permit,is for one hundred dollars ($100) or less.) LAVATORY ADDRESS f -
1 certify that in the performance of the work for which this per- n
' mit is issued, I shall not employ any person in any manner so SINK V� CITY TEL NO.
as to-become subject to the Workers' Compensation Laws. DISHWASHER f
i. CONTRACTOR .]• e.f' C -
Date - - Applicant CLOTHES WASHER ADDRESSrJ
NOTICE TO APPLICANT-: If,-after making this Certificate of Ex- < C
f SWIMMING POOL RECEPTOR
emption, you should become subject to the Workers'Compen- CITY ^'--.; TEL!NO. � �'?.
sation provisions of the Labor Code, you must forthwith comp LAWN SPRINKLER'SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE l LIC.';
ed. WATER HEATER LICENSE NO. Cf/ CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO: PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS z,leg /y
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER C�
5 PER SYSTEM f
and Professions Code, and my license is in full force and ef- FINAL VALIDATI
fect. /t DATE
�s�
I License Number 1 �/ , W7 Lic. Class U
FINAL
Contractor C [— _Date Kf BY O
I am exempt under Sec.
B.&P.C. for this reason Plan CheCIC fee
Poo :907
a.
Date: PLUMBING PERMIT ISSUING.FEE$ ho
Signature r�
#' 0 0 0 o
TOTAL FEE e
SINGLE FAMILY 0 - 46.5 0
ME OWNER-BUILDER DECLARATION Plan check applicant
1 hereby affirm that I am exempt from'the Contractor's License Name ® 0 046505
Law for the following reason (Section 7031.5, Business and i _ 0 9.12 J-&8
Professions Code): Address
1, as owner of theproperty, will do the woik and the :City Tel.,No.
structure is not intended or,offered.for sale(Section 7044;
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
1
I hereby affirm that there is a construction lending agency for
the performance of.the work for which this permit is issued
i (Sec..3097, Civ. C.).
Lender's Name
i
Lender's Address.
I certify that I have read this application and state that the j
above'information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
i" authorize representatives of-this-County to enter upon the
P p p P
above-men d ro ert forti,ns-e .Ion ur ose . �
v6 C_ c SEE.REVERSE FOR EXPLANATORY LANGUAGE
I .
Signatur of Per itt a Date '
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