HomeMy Public PortalAbout6018 ALESSANDRO AVE_Plumbing__ 1'
WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
V I FArel�y affirm that I have a certificate of consent to self 76A667A
insu a or a certificate of Workers Compensation Insurance CE 817 (REV 8/86) �J
or a certified copy thereof (Sec 3800 Lab C )
COUNTY OF LOS ANGELES` DEPT OF PUBLIC WORKS
❑
Policy No Company 1`t + A 1 t 1
Certified copy is hereby furnished c
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING* � 4 `�� ��
❑ Certified copy is filed with the county building inspec ADDRESS
no
tion department NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant WATER CLOSET r NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
COMPENSATION INSURANCE i OWNER
SHOWER
(This section need not be completed if the work involved by MAIL
the permit Is for one hundred dollars ($100)or less) LAVATORY ADDRESS
I certify that in the performance of the work for which this -
permit is issued I shall not employ ny person in any nner CITY TEL NO�--7
so as to'become subject to the rk rs Compe Laws DISHWASHER
CONTRACTOR CAI
Date/X-Dpplico _ CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making this Certificate of
Exemption you should become subject to the Worker SWIMMING POOL RECEPTOR CITY TEL NO
Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO P OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER •/T�
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINALIL
iJ Quo VALIDATION
DATE (� U 0
License Number Lic Class
FINAL cc
Contractor Date BY O
r V
❑ 1 am exempt under Sec t 91.1611.
B 8P C for this reason H
Plan check fee �
` Date PLUMBING PERMIT ISSUING FEE$ v
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Name hLy, Cc,
I hereby affirm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 5 Business and Address om
Professions Code) City Tel No ;98668A
I as owner of the property will do the work and the # 0 0 a 0 ° 5
structure is not intended or offered for sale (Section
7044 Business and Professions Code) ° ° 4 6 5 0
CONSTRUCTION LENDING AGENCY - °i° 4 61 5 0 c=�
1 hereby affirm that there is a construction lending agency for Ii 2,27-87
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 t
above mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignoture ot1kne Date