HomeMy Public PortalAbout6042 ALESSANDRO AVE_Plumbing__ WORKERS COMPENSATION DECLARATION 76A667A
I lsreby,�affirm that I have a certificate of consent to self CE 617 (2 60) APPLICATION FOR PLUMBING, PERMIT {�
insure or a certificate of Workers Compensation Insurance or J
a certified co reof(Sec 3800 Lab C)
011/1;z 10y i- � i {/� / COUNTY OF LOS ANGE ES BUILDING AND SAFETY
Policy N0 Company�I4�+a5QL �j ,
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ��
C/G L' SAA41
Certified copy is Bled with co "'ty buildin nspec on NUMBER FIXTURE OR ITEM • FEE ADDRESS
depart en LOCALITY
WATER CLOSET
Date Applicant NEAREST or
BATH TUB CROSS ST
CERTIFICATE OF EXE TION FROM WORKERS
COMPENSATION INSURANCE SHOWER OWNERJJ ,qj)1MAI L
(This section need not be complete f the work Involved LAVATORY ADDRESS 6879 drJ 04A221eb
by the permit Is for one hundrg dollars ($100) or less) ?'j a
/ SINK CITY �g ��' TEL NO��S S oc� 0
1 certify that in the performance of the work for which this U
DISHWASHER CONTRACTO
permit is Issued I shall n employ any person in any manner &SL A"q/— '
so as to become suble to the Workers Compensation Laws CLOTHES WASHER ^ n
ADDRESS '2S/O C 1t?4/6 A
Date pt
SWIMMING POOL RECEPTOR U
NO/revoked
PLICANT If after making this Certificate of CITY wet TEL NO dat 6 find d
Exeou should become subject to the Workers LAWN SPRINKLER SYSTEM
N
Comprovisions of the Labor Code you must forth STATE 3 Fir D p LIC \ Z
withwith such provisions or this permit shall be WATER HEATER LICENSE NO Ftp 0 GLA S v —
dee 1 GAS SYSTEM OUTLETS DISTRICT NO P ESS Y
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi FINAL VALIDATION
ness and Professions Code and my license is in full force and DATE
effect
License Numbe� 0 _"Lic Class BY
NAL
) ESrd Edrm-z
Contractor EF/IlliC Date
❑ I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professignal engineer
acting in my professional capacit/e—
n 7051 Bus PLUMBING PERMIT ISSUING FEE$
mess and Professions Code) TOTAL FEE a
Lic or Reg No Plan check applicant
HOME OWNER BUILDERDECLARATION Name
I hereby affirm that I amexe pt from the Contractors
Address
License Law for the following anon (Section 7031 5 Busi City Tel No
ness and Professions Code)
❑ I as owner of the pro erty am exclusively contracting
with licensed contra ors to construct the project
(Section 7044 Busi ss and Professions Code) 3 5 G 9 A
CONSTRU TION LENDING AGENCY
I hereby affirm the there is a construction lending agency # o o o o a 5
for the performaKice of the work for which this permit is
issued(Sec 30 '7 Civ C) 2 ° 1 2 5 0
Lender s Name
010 o 1 2500'i
Lender s Address
I certify that I have read this application and state that the 1229-80
above information is correct I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing and hereby f
auth ize representatives of this County to enter upon the
ab e m ntioned pro erty f inspection purposes '
/
Date
nature of Permittee