HomeMy Public PortalAbout6013 ALESSANDRO AVE_Plumbing__ 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)
or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No/Company , `-e
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
0-11Cerhfied copy is filed with the county building mspec ADDRESS
tion department r NUMBER FIXTURE OR ITEM @ FEE LOCALITY Temple Cl
ty
q_ WATER CLOSET
Date ApplicantNEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS
BATH TUB CROSS ST
COMPENSATION INSURANCE OWNER
SHOWER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less ) _ LAVATORY ADDRESS 6013 Alesan&o
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner / SINK �) CITY T le Cil TEL NO 287_3070
so as to become subject to the Workers Compensation Laws DISHWASHER
0-0 CONTRACTOR Universal Plunbixia
Date Applicant CLOTHES WASHER 010 ADDRESS
NOTICE TO APPLICANT If after making this Certificate of 2631 TPP-AVP
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth CITY TEL NO
LAWN SPRINKLER SYSTEM So ZL mm.te 575-3460
with comply with such provisions or this permit shall be STATE LIC /7 �]/
deemed revoked I WATER HEATER LICENSE NO CLASS e3l1
LICENSED CONTRACTORS DECLARATION DISTRICT NO r P ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ('j-Q
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER CLCL
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAh 0
DATE
V
/Q VALIDATION
License Number 3 R(e 4- -7 p p Lic Class C
FIN
i.P� Y,:: S v 9—c BY Im
AL O
Contracto �e �-� V
I am exempt under Sec H
B 8P C for this reason Z
Plan check fee
Date 111101 PLUMBING PERMIT ISSUING FEE$ U
Signature
TOTAL FEE
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 „ 4 5 !1 4 A
Professions Code) City Tel No #t o 0 0 0 05
❑ 1 as owner of the property will do the work and the 2 0 0 3 o o 0
structure is not intended or offered for sale (Section
7044 Business and Professions Code) 01 0 3,�5 O U
CONSTRUCTION LENDING AGENCY 0 a'1 7-8 3
1 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
�ementionecl property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
R-0-
Signature ermittee Date