HomeMy Public PortalAbout5839 ALESSANDRO AVE_Plumbing__ 4 WORKER'S
I" COMPENSATION,of consent to 76A666DPW9/89 APPLICATION FOR PLUMBING PERMIT ,f�I
76A667A 11
I hereby affirm that I"have a certificate of consent to self insure, LLLJJJ
or a certificate of Worker's Compensation Insurance, or a certified
copy therz0f.($2c.:800 Lab. C.)
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
Policy No. Company
❑ Certified copy is hereby furnished. `
El Certified
APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
ADDRESS ler ti✓`Z Q
Certified copy is filed with the county building inspection
department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY � !` C L
Date Applicant WATER CLOSET (� NEAREST
CERTIFICATE OF-EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE BATH TUB
ASSESSOR
(This section need not be completed if the work involved by the
SHOWER MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) LAVATORY OWNER L .0
1 certify that in the performance of the work for which this permit MAIL
is issued, I shall not employ any person in any manner so as to / SINK ADDRESS
become subject to the Workers' Compensation Laws.
DISWASHER QO CITY TEL.NO.
Date Applicant CLOTHES WASHER ('� CONTRACTOR
NOTICE TO APPLICANT: If, after making this Certificate of luwvfi
Exemption, you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code, you must forthwith comply with such S ^L �,�
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CI C TEL.NR/g 3.71 �y/,3y-
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER
(commencing with Section 7000) of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSTATE LI SE NO. CLASS C• ✓t V
Professions Code,and my license is in full force and effect. DISTRICT NO. D BY
OUTLETS OVERIr
G 5 PER SYSTEM . 09 0
License Number l S L�'/ Lic.Class
FINAL VALIDATIONW
3 DATE `9
Contrac r—/c�� 6 V v �� 1 a it
CD
IDFINAL .r -)i 1 s�i 4w i i•.a:r_s
I xempt under Se BY
BAP.C.for this reason TOTAL;AL 1 15 ® 65
Plan check fee
i� 1
Date: • , !: _l.•�; t_}a L'_F
PLUMBING PERMIT ISSUING FEE$
Signatur ` _:KY NGE a I_
❑ TOTAL FEE !
Plan check applicant _
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law 5154 . 1 tis E";--J
for the following reason (Section 7031.5, Business and Professions Address _...
Code):
❑ City Tel. No.
I, as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, 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. rtq to enter upon the above-mentioned
proper r inspe n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Si o Permit a Date