HomeMy Public PortalAbout5827 ALESSANDRO AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm' that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished.
r-1Certified
APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS 217, ALt5SAIJD)2 t5 A\T,
tion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. LA s -rVOAS PSP
COMPENSATION INSURANCE OWNER L
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL ADDRESS '-T 2-7 ALESSAfJ1>R0 A`VF,
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY ��`l/ G/'� l TEL. NO.
so as to become subject to the Workers Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER �D f
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
License NumberLic. Class DATE 1 j -�) 0
0,
FINAL
Contractor Date BY ®;
❑ I am exempt under Sec.
W.
B.&P.C. for this reason Plan check fee ® B�lD
Signature Date:
PLUMBING PERMIT ISSUING FEE$
TOTAL FEE Bre
SINGLE FAMILY Plan check•applicant
HOME OWNER-BUILDER.DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the - 1 9� 1=r
structure is not intended or offered for sale (Section
7044, Business and Professions Code). ® E, aa
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 "k;`.�' "
(Sec. 3097, Civ. C.).
Lender's Name
1 I lki TI.-. ii`i (7 i i?j Fc:
S.
Lender's Address 1# �'ji _
1 certify that I have read this application and state that the 1•`_i
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize represe fives of this County to enter upon the
above-m ned'p perty for i pec ion purposes.
/7- SEE REVERSE FOR EXPLANATORY LANGUAGE
re of Per ee Date