HomeMy Public PortalAbout6029 ALESSANDRO AVE_Plumbing__ WORKERS'.COMPENSATION DECLARATION 2DPW 4/87 APPLICATION FOR PLUMBING PERMIT
• I•hereby„affirm that I•have a certificate of corsent to self in- 76A6676A667A
sure,,-or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86)
certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES _ DEPT. OF PUBLIC WORKS
Policy No. Company
Fj Certified copy is hereby furnished.
` FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection e—
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date ' Applicant WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' `
BATH TUB CROSS ST.
COMPENSATION INSURANCE i SHOWER / OWNER
(This section need not be completed if the work involved by �7 /� MAIL /` G
the permit is for one hundred dollars ($100)or less.) LAVATORY UV ADDRESS !r
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CITYTEL. NO. r
'12-
as to become subject to the Workers pensation Laws. DISHWASHER
CONTRACTOR
Date' Applicant CLOTHES WASHER ADDRESS (�
NOTICE TO APP (CANT: If, after making this Certifi ate of Ex-
emption,you should become subject to the Workers'Compen-. SWIMMING POOL RECEPTOR
CITY TEL. NO.
cation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PRO SED B
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division'3 of the Business OUTLETS OVER U
fed Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VAL &TION
DATE O
License Number Lic. Class V
FINAL
Contractor Date BY O
t'
0 1 am exempt under Sec. Q
B.BP.C. for this reason ,
Plan check fee g
Date PLUMBING-PERMIT ISSUING FEE$
Signature o
TOTAL FEE5 0 b
SINGLE FAMILY o
MA
HOME OWNER-BUILDER DECLARATION Plan check applicant G o a 3i�5 O U
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and 1qrW® � 0 66 b $ `
Professi s Code): Address.
I, as,
owner of the property, will do the work and the City beTel. No.
M -
structure is not intended or offered for sale(Section.7044,
Business and Professions Code).
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
.1 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
abov tione operty or inspectioN71,.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date