HomeMy Public PortalAbout5731 ALESSANDRO AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION
20-0026 DPW 4/90 APPLICATION FOR PLUMBING PERMIT
I herebV.,,affirm that I have a certificate of consent to self in- 76A667A
.,sure)or a certificate of Workers'Compensation-Lpsura'nce�or a n
certified copy thereof (Sec. 3800, Lab. C.) U
Policy No. Company 9�/s �f COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
❑ Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
Certified copy is filed with the county building inspection ADDRESS
depart en. d NUMBER FIXTURE OR ITEM @ FEE LOCALITY
D d t e
V Applicant V`�" �_� WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER / D OWNER
(This section need not be completed if the work involved by dC� MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CITY TEL. NO.
as to become subject to the Workers' Compensation Laws.. DISHWASHER �
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS �6/o0 "Ajew
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY K� TEL. NO. a I LG o
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of'the Business OUTLETS OVER
and Professions Code, and my license is in fullforce and ef- 5 PER SYSTEM FINAL VALIDATION
fect. HOSE BIB DATE
ti
License Number-r-&-.706 Lic. Class /. ' �_ t // r O
y �(� �rj ;11) 7(1 /lO 0 FINAL c 0
Contractor `rf 1L'ZO� Date
AC:C:T a g o
1 am exempt under Sec.
03 75e
B.&P.C. for this reason Plan check feeLU
, C
1 ITEMS
Date: PLUMBING PERMIT ISSUING FEE$ TOTAL ^��^ CA
CA
Signature TE ITAL f -_a ® 601
SINGLE FAMILY TOTAL FEE GHELCK 75.60
HOME OWNER-BUILDER DECLARATION Plan check applicant CHANGE .00
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 0000-0001 • 4/ 8/96
I, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044, �}�69 1 � :35
-�-�
Business and Professions Code), ,
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 Name
Lender's Address
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
above- entioned property for inspectiongp�pes.rSEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Da are