HomeMy Public PortalAbout5801 ALESSANDRO AVE_Plumbing__ ION
DECLARAT
WORKER'S I have
a c,eSATate of consent to 76A666DPW9/89 APPLICATION FOR PLUMBING PERMIT
76A667A
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab. C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
El Certified copy is hereby fur isheecl
❑ Certified copy is with h cBUrlty ding inspe FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING l I�� K�j /��
J ADDRESS ( (�L p�
department. C r'1 NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Appli i WATER CLOSETt
NEAREST
CERTIFICATE EXEMPTI OM WORKERS' BATH TUB CROSS ST. Cep 7fc n`
*' COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the ISHOWER MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) LAVATORY OWNER
1 certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to SINK MAIL
ADDRESS
become subject to the Workers'Compensation Laws. SG✓�
DISWASHER CITY � � TEL.NO.
Date Applicant CLOTHES WASHER CONTRACTOR )
NOTICE TO APPLICANT: If, after making this Certificate of ��
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO.
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER A5 �.
(commencingwith Section 7000 of Division 3 of the Business and STATE LIC.
) /
Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. CLASS 0
OUTLETS OVER DISTRICT NO. PffF.9SED BY IIm
5 PER SYSTEM o
License Number Lic.Class �!
FINAL A
DATE VALIDATION
Contractor Date
❑ I am exempt under Sec. BY AL
B.&P.C.for this reason
Date: Plan check fee ►
Signature PLUMBING PERMIT ISSUING FEE$
ElTOTAL FEE J
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name a'_• t =
1 hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions Address
Code):
City Tel. No. f _?
I,as owner of the property,will do the work and the structure _
is not intended or offered for sale (Section 7044, Business iii`:6SL
and Professions Code). ' r -rr
CONSTRUCTION LENDING AGENCY _
I hereby affirm that there is a construction lending agency for the ('i'Ft ll-
performance of the work for which this permit is issued (Sec. 3097,
Civ.C.)
Lender's Name j`y fHLM
C.
'
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-mentioned
propert or inspection purpses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Slgnatl#6 of Permittee Da e