HomeMy Public PortalAbout5934, 5934 1/2 ALESSANDRO AVE_Plumbing__ I� WORKERS COMPENSATION DECLARATION _, APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
insure or a certificate of Workers Compensation Insurance CE 817(REV 10/81)
ora certified copy thereof (Sec 3800 Lob C ) COUNTY OF LOS ANGELES > BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished BUILDING
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy is filed with the county building mspec
tion department NU ER FIXTURE OR ITEM Q FEE
LOCALITY ,
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS S
COMPENSATION INSURANCE OWNER
il
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars ($100)or less ) MAIL
LAVATORY ��}
ADDRES
I certify that in the performance of the ork for which this v
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permit is issued I shall not employ an a son in any manner SINK CITY L NO
so as to become subject to the Work s mpensation Laws DISHWASHER
CONTRACTOR
Date /L-/,5 Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making this Certificate of ��
Exemption you should become subject to the Workers I MING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth CITY
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM
STATE LIC
deemed revoked WATER HEATER LICENSE NO CLASS (r.
LICENSED CONTRACTORS DECLARATION DISTOCTINO ROCESSED B
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is in full force and effect 5 PER SYSTEM
FINA./ i�
DATE �� VALIDATION v
yLicense Number � .2�.v2 If Lic Class
,�� FINAL �
Contractor ������'`LLt 5 Date — — BY
❑ I am exempt under Sec /_ d
B&P C for this reason /�J W
Date
Plan check fee Z
,
PLUMBING PERMIT ISSUING FEE$ 41
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER BUILDER DECLARATION Name 8 9 Lt 9 A
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 1" c 1 o o o o5
❑ I as owner of the property will do the work and the G o 1 4 2 5 0
structure is not intended or offered for sale (Section
7044 Business and Professions Code) do o 1 42 5 0 f2
CONSTRUCTION LENDING AGENCY 1 5-8 4
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 ) r
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
ordinas and State jaws regulating Plumbing and hereby
autho iz representatives of this County to enter upon the
abov noon roperty for inspection purposes
t SEE REVERSE FOR EXPLANATORY LANGUAGE
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Sign lure o ermitI Date
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