HomeMy Public PortalAbout5936 ALESSANDRO AVE_Plumbing__ WORKERS COMPENSATION DECLARATION . ` I 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)
or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished
F-1Certified
APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec ADDRESS e
tion department NUMBER FIXTURE OR ITEM @ FEE WATER CLOSET LOCALITY e
I , r
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB ROSS ST Cj &
COMPENSATION INSURANCE SHOWER OWNER s
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less ) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CITY TEL NO�
so as to become subject tothe Workers Compensation Laws DISHWASHER
X/ � CONTRACTOR
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Dat e7 �l Applicant A CLOTHES WASHER
NOTICE TO APPLICANT If after making A CertificateJbe
ADDRESS
Exemption you should become subject to the WorkSWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must foLAWN SPRINKLER SYSTEM CITY TEL NO
with comply with such provisions or this permit shall STATE LIC
deemed revoked WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 0
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER y,
and Professions Code and my license is in full force and effect 5 PER SYSTEM .15: FINAL VAUMRATION
License Number Lic ClassDATE
4 FIN O
Contractor Date 1—
❑ u
I am exempt under Sec W
CL
B &P C for this reason H
Plan check fee Z
D PLUMBING PERMIT ISSUING FEE$ 4 A
Signature
TOTAL FEE fj o c o 0 0
Plan check applicant
SINGLE FAMILY °FO 2 G 5- 0
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s License o 010 Ex J 0
Law for the following reason (Section 7031 5 Business and Address
Professions Code) 0308-84
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
1
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 9
ordinances and State jaws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
,efipv entioned pr perty for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature o Permittee Date