HomeMy Public PortalAbout5420 ACACIA ST_Plumbing_11/9/1992_Bathroom plumbing • WORKER'S COMPENSATION DECLARATION _ 200028 DPW 9/89r APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self Insure, 78A667A
or a certificate of Workers Compensation Insurance, or a certified
copy thereof(Sac 3800 Lab C) ^, '
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV
Policy No r Company ' + d ,\n
,
Certified copy is hereby furnished f ,
❑ � � --FOR APPLICANT TO-FILL IN(PRINT OR TYPE) ABUILDING
DDRESS
Certified copy,is filed with the county budding Inspection
` department NUMBER FIXTURE OR ITEM @ FEE LOCALITY !•
Date Applicant WATER CLOSET /0 NEAREST r
r
• CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST
�r BATH TUB � � • '
COMPENSATION INSURANCE / ASSESSOR
(This section need not be completed if the work involved by the SHOWER MAP BOOK j' PAGE.;�'A1- PARCE�,J;t.17`
permit is for one hundred dollars($100)or less) LAVATORY ` OWNER ' 7 47ovO - ✓47t/
I certify that-in the performance of the work for_which this permit /0
is Issued, I shall not employ any person in any manner so as to SINK MAIL
become sub/ed to the Workers'Compensation Laws t ADDRESS
DISWASHER CITY 9A4_ TEL NO
Date Applicant CLOTHES WASHER CONTRACTOR-
Exemption,
ONTRACTOR_
NOTICE TO APPLICANT If, after making this Certificate of _
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR +
provisions of the Labor Code, you must forthwith comply with such ADDRESS
provisions or this permit shall be deemed revoked ( LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL NO
I hereby affirm that I am licensed under provisions of Chapter 9 - WATER HEATER a,
(commencing with Section 7000)'of Division 3 of the Business and STATE LIC '
Professions Code,and my license is,in full force and effect _ GAS,SYSTEM .2 OUTLETSLIZAJI LICENSE NO . CLASS 8
` OUTLETS OVER DISTRICT NO PROCESSED BY IT
5 PER SYSTEM O
License Number Lic Class I—
' _ FINAL VUIDATION W
DATE Z 1•-Q r
Contractor _ y Date ` f 1 {rTh n'
i FINAL 1�`ti l e'C y
I am exempt under Sec �y _ Z
_ B&P C for this reason' '
Date Plan check fee , i ITEM_
Signature
PLUMBING PERMIT ISSUING FEE$ �L� 'TO�AL 1,70 0 125
�
❑ TOTAL FEE, d a „ CHECK r■i
SINGLE FAMILY Plan check applicant , ,^ CHANGE .0))
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031 5, Business and Professions Address
Code
I/- City Tel NO + �t ri i ('•I {
I as owner of the property,will do the work and the structure 6392 ,I AM �0
•
is not intended or offeredl for sale(Section 7044, Business ++
and Professions Code)
i CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the + v
performance of the work for which this permit is issued(Sec 3097,
Civ C) +
Lender's Name
Lender's Addressr
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 - - \ r
representatives of this County to enter upon the above mentioned I
` `proper[ ti purposes "SEE REVERSE-FOR EXPLANATORY LANGUAGE
Signature of Permittee Date