HomeMy Public PortalAbout5302 ZADELL AVE_Plumbing_11/18/1986_ WORKER'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affi?m that I .have a certificate of consent to self 76A667A
insure, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) II��
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy NciZWA Company 51W Fwdw -
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) gDDRESS� Z1+
Certified copy is filed with the county building inspec-
tion department. Af
NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date IL1W Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM RKERS' ,
BATH TUB CROSS ST.
COMPENSATION INSURANCE I SHOWER OWNER lle• [ s
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner SINK CITYt TEL.NO.
so as to become subject to the Workers'Compensation Laws.
DISHWASHER CONTRACTOR
`1co"G, /uaCMJ
Date Applicant CLOTHES WASHER ADDRESS,nn,,
NOTICE TO APPLICANT: If, after making this Certificate of ; W+ K• M.
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR QIr
CITY j.4figyr TEL.NO.
Compensation provisions of the Labor Code, you must forth-
A.
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM 1 �— STATE ' LIC.
deemed revoked. WATER HEATER LICENSE NO. 3 SS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. MOCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �^ 6 t
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,
,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
I DATE a
License Number Lic. Class C
Contractor Date 1 � a/ � BY BY ✓
❑ I am exemp nder Sec. n/ C
B.BP.C. for this reason
Plan check fee p,
Date: PLUMBING PERMIT ISSUING FEE$ -v
cor
Signature
TOTAL FEE
SINGLE FAMILY
Plan check applicant 1
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
Professions Code): I City Tel. No.
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section I ® ;95968A
7044, Business and Professions Code). # 0 0 0 0 0 5
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for Io 0 1 b 5 0
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.). I o o,o 1 6505
I
Lender's Name 1.18"86
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County I
1111110.
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the I
above-men ioned property for inspection purposes. I
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Per r
e Ocife