HomeMy Public PortalAbout5848 ALESSANDRO AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �7
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 ereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No(;�orrf. any
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE)
Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY
Date � Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTIO OM WORKERS' BATH TUB CROSS ST.
e COMPENSATION I,SURANCE OWNER
(This section need not be completed if the work involved by SHOWER +
the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL
ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK / O CITY i-eZTEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER I
CO
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL. NO. t
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS G
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm That I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER O
and Professions Code,a d my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
/�
License Numberf�KLic. Class-C�ri— DATES �1 "l�� ®,
FINAL �
Contractor %'���ZC 0r Date BY ::i0.
❑ I am exempt under Sec. :; ;` ::
Its
B.&P.C. for this reason Plan check fee - - - Cl)
Z
Date:
Signature PLUMBING PERMIT ISSUING FEE$ - -
�
TOTAL FEE 3 �� - e iL •. _ _� r€
Plan check applicant -
SINGLE FAMILY t t -
HOME OWNER-BUILDER DECLARATION Name _a>t€au•_ __j
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. ;":e rni-'-•;? j i y "'
❑ I, as owner of the property, will do the work and the -=m•-, - y - ' '
structure is not intended or offered for sale (Section '"
7044, Business and Professions Code). 001
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-mentioned property or inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si Lure of Permittee Date