HomeMy Public PortalAbout5720 ALESSANDRO AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION
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I hereby, affirm tha.l I2tSve•a e2+.ctificJte'gf consent to self tri- 20-6026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT76A667A
sure,or a tertificaie'of Workers'C�7;mp;the tion Irisu'rance,or a CE 817(REV. 8/86) ILJI
ce;-fi��opy thereof (Set.. 3 0, Cab. C.)
G✓ y ��o�� S� P y ��yf7i�y����)Y COUNTY OF LOS ANGELES DEPT: OF.PUBLIC WORKS
Pot`c CC om an (JY
❑ Certified copy is hereby furnished. .
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING /
�ertified copy is filed with the county building inspection ADDRESS ZQ �G
NUMBER FIXTURE OR ITEM LOCALITY
department. @ FEE E�� Z,-
Date
� C
Z WATER CLOSET(TOILET) n/I
Date 7 !L/ Applica f' ' NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' 2 BATH TUB 0 CROSS ST.
COMPENSATION INSURANCE �(_f__ SHOWER `� OWNER
(This section need not be completed if the work involved by 0 MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY !-V' ADDRESS
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so 750 CITY TEL. NO.
as to become subject to the Workers'Compensation Laws. DISHWASHER a
CONTRACTOR L
Date Applicant / CLOTHES WASHER
NOTICE TO-APPLICANT:,If, after making this Certificate of Ex- ADDRESS
emption; you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR
CITY TEL. NO.��
'
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ���✓
ly with such provisions or this permit shall be deemed revok- STATE LIC >
ed WATER HEATER U LICENSE NO.G -2 CLASS G
LICENSED CONTRACTORS DECLARATION' v DISTRICT NO. ACES Y
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 7,10
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL V LID ON D'
fect. 7 r'
License Number � �� Lic. Class
7 G/ DATE O
�� �1 \ BYAL
U
Contractor Date 7i / O
I am exempt under Sec. V
B.&P.C..for this reason 0.0.
Plan check fee ► g
Date: PLUMBING PERMIT ISSUING FEE$
Signature
- TOTAL FEE
SINGLE FAMILY
HOMEOWNER-BUILDER DECLARATION -Plan check applicant }
I hereby affirm that I am exempt from the Contractor's License Name Ar
Law for the following reason (Section 7031.5, Business and N ( °
Professions Code): Address
.63071
I, as owner of the property, will do the work and the City Tel No. 11�=1_�MS
structure is not intended or offered for sale(Section 7044, _
1
Business and Professions Code). TOTAL 125 50
CONSTRUCTION LENDING AGENCY ► {,HE .K3t�'G s 5 Irl
' .t•.
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CHANGE
(Sec. 3097,3097, Civ. C.).
Lender's Name1_ ' 2/ i/''r
Ll
Lender's Address 8-" ail'
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
abov �tionproperty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date