HomeMy Public PortalAbout6033 ALESSANDRO AVE_Plumbing__ WORKER'S have
a'ceSATIONDEConsent to 76A626DPN/9/89 APPLICATION FOR PLUMBING PERMIT
76A667A
I hereby affirm that) have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof'(Sec.3800 Lab. C.)
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
Policy No. Company
❑. Certified copy is hereby furnished. BUILDING 1'
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS1e5Cjr/!�j(/dr Q
❑ Certified copy is filed with the county building inspection
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
>!`i
Date Applicant WATER CLOSET
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE ASSESSOR
MAP BOOK PAGE PARCEL
(This section need not be completed if the work involved by the SHOWER -
permit is for one hundred dollars($100)or less.) OWNER OO yy
I certify that in the performance of the work for which this permit LAVATORY
is issued, I shall not employ any person in any manner so as toMAIL
SINK ADDRESS v
become subject to the Workers' Compensation Laws.
i� fir' /� �7/B DISWASHER CITY �� TEL.NO. _
Date ✓—���( Applicant f! -4� � �2 CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR �J
Exemption,you should become subject to the Workers' Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY ,�9�sap TEL.NO. /
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER `^�� 0 �7�T
(commencing with Section 7000) of Division 3 of the Business and STATE LIC. /� 6 0
Professions Code,and my license is in full force and effect.
GAS SYSTEM OUTLETS LICENSE NO. �7 CLASS C' 0
OUTLETS OVER DISTRICT NO. PROCESSED BY cc
s �/— 5 PER SYSTEM
License Number ✓ � 14 77 Lic.Class ` 8
/(�/ /-�/ ,�.�,/J, •� FINAL VALIDATION W'
//�WN'7/-44�ZD� 3'p'q_y 3 DATE 1 —� n.
Contractor Date r (n
❑ I am exempt under Sec. FBY
INAL Z
B.&P.C.for this reason
Plan check fee ,
Date:
Signature
PLUMBING PERMIT ISSUING FEE$
❑ TOTAL FEE
SINGLE FAMILY
Plan check applicant
a
HOME OWNER-BUILDER DECLARATION NameI •ti- or
I hereby affirm that I am exempt from the Contractor's License Law _ �'y
for the following reason (Section 7031.5, Business and Professions Address 4,1141��6 � , _6U i V o 65
Code):
r_1 1,
r>A1r& E Tel. No. 2 7 '?7 Cr ! �T EM
I,as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business )01 T AIL 40 m 65
and Professions Code).
'CHECK
c
CONSTRUCTION LENDING AGENCY t i GEc
I hereby affirm that there is a construction lending agency for the CHANGE °013
performance of the work for which this permit is issued (Sec. 3097,
Civ.C.)
00100-0001 3r24A93
Lender's Name 885-26 1 M{
-Lender's Address
I certify that I have read this application and state that the above 000.information is correct. I agree to comply with all County ordinances
and State laws regulating Plum ing, and hereby authorize
represen fives of this Count to a ter upon the above-mentioned
prole for inspection pur
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date