HomeMy Public PortalAbout5431 BALDWIN AVE_Plumbing__ (2) APPLICATION FOR PLUMBING PERMIT
WORKERS' COMPENSATION DECLARATION
I�hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
inswe, or a certificate of Workers' Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No^ Company
❑ Certified copy is hereby furnished.
7 FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING L r
Certified copy is filed with the co my buildin inspec- ADDRESS ( V
tion d arimeni /y), /, NUMBER FIXTURE OR ITEM @ FEE LOCALITY �P�2 S--CMZ, c�
Date plicant. ��r�f�" WATER CLOSET OG '� NEAREST j
CERTIFICATE OF EXEMPTION FROM WORKERS' .2— BATH TUB CROSS ST. d/ t✓ "�
COMPENSATION INSURANCE SHOWER OWNERS
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100)or less.) MAIL
LAVATORY
ADDRESS
I certify that in the performance of the work for which this /
CITY TEL. NO.
permit is issued, I shall not employ any person in any manner SINK
so as to become subject to the Workers Compensation Laws. DISHWASHER _
CONTRACTOR • 'C
Date Applicant-:-_ CLOTHES WASHER r
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS �0,�5v X / S�f 2-
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY �- TEL. NO. yL f5
Compensation provisions of the Labor Code, you must forth- ` P
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. r Ys WATER HEATER LICENSE NO. i% p / V CLASS 3
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 r GAS SYSTEM / ^ S OUTLETS ^ G�
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINA
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Vol VALIDATIO
b..- Li ense Number Z� Lic. Class v DATE 0
+� FINA Ix
Contractor4f, e z^^ Date d rJ FI �I 0.
❑ I am exempt under Sec. / J
B.BP.C. for this reason f @�
Plan check fee ® U,
Date:
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name s
1 hereby affirm that I am exempt from the Contractor's License Address ACCT.v
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. 33307 112.50
❑ I, as owner of the property, will do the work and the ° 1 ITEMS
structure is not intended or offered for sale (Section
7044, Business and Professions Code). ® TOTAL :1112®0-50
CONSTRUCTION LENDING AGENCY CHECK 112.5-AI hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CHANGE .00
(Sec. 3097, Civ. C.).
Lender's Name 0000-0001 8/23/839
Lender's Address 524 1 AM 9:04 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
abo - entioned'pr perty for inspection purposes.
�� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date