HomeMy Public PortalAbout5745 ALESSANDRO AVE_Plumbing__ WORKER'S COMPENSATION DECLARATION 20-0026 DPW 9/89
1 hereby affirm that I have a certificate of consent to self insure, 76A667A APPLICATION FOR PLUMBING PERMIT
or a certificate of Worker's Compens ' Insurance, or a certified
copy ther (Sec.3800 Lab. C.)
/COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
Policy No ��_ Compa
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified co y is filed with the ounty bui ding inspection
((( �d arSm NUMBER FIXTURE OR ITEM @ FEE LOCALITY i
Dat fG Applican WATER CLOSET S r NEAREST `G
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CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.� S /'
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) LAVATORY OWNE DAl / i' d
I certify that in the performance of the work for which this permit 'v S
is issued, I shall not employ any person in any manner so as toMAIL
/ SINK D ADDRESS r 69X
become subject to the Workers'Compensation Laws.
/ DISWASHER O CI
Date Applicant CLOTHES WASHER —D rf
NOTICE TO APPLICANT: If, after making this Certificate of CON
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDR y/ i
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CIT T
I hereby affirm that I am licensed under provisions of Chapter 9
WATER HEATER v �,
(commencing with Section 7000) of Division 3 of the Business and STATE LIC.
Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS 1 p LICENS
'2E NO. 9 CLASS
�/J��f Q����y/ OUTLETS OVER DISTRICT f PROCES ED BY
5 PER SYSTEM
License Number
/ /, �' / Lic.Class ✓ y
AWWD
J FINAL VALIDATION W
DATE _ Gf
Contract D O / ca
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❑ 1 am exempt under Sec. BY AL
B.&P.C.for this reason
Plan check fee ,
Signature Date: Q
PLUMBING PERMIT ISSUING FEE$ 3
❑ TOTAL FEE
Plan check applicant
SINGLE FAMILY "
HOME OWNER-BUILDER DECLARATION Name
hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions Address
Code): 14
❑ City Tel. No. 7-
1,as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business ?'',f I H".,,
and Professions Code). ,
i . �
.s LE K
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.) i}
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Lender's Name
E .4 i}ja
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
re esentatives of this County to enter upon the above-mentioned
P
op r or ins p rpose . .� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date