HomeMy Public PortalAbout5325 ZADELL AVE_Plumbing_9/27/1991_ (2) " 'WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I'ltereby, affirm that I have a certificate of consent to self in- 26DPW 4/87 n
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sure,or a certificate of Workers'Compensation Insurance,ora CE 817(REV.8/86)
certified copy thereof(Sec. 3800, Lab. C.)
ff� COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No.L6 +Company —
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS ,
department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date Applicant WATER CLOSET(TOILET)
NEAREST
CERTIFICATE OF EXEMPTION OM ORKERS' BATH TUB
COMPENSATION I URAN�E SHOWER OWNER f
(This section need not be completed if the work involved by _ MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY �ij / [ ADDRESS 2
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so SINK CITY LI c
r TEL. NO
as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER /�(��
ADDRESS a
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption,you should become subject to the Workers'Compen- CITY
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM TEL. NO d^
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO.
CLASS
LICENSED CONTRACTORS DECLARATIONDISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM + OUTLETS I I �j"�' _
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
fecf. DATEZ 7 a0
vYY
License NumberLic. Class V
FINAL Q
Contractor C%�(�+ C'L 9beIe . ^0 BY O
U
I am exempt under Sec.
B.BP.C. for this reason Plan check fee U)
Date: PLUMBING PERMIT ISSUING FEE$
e-(
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION PP icant
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business.and
H`::- °
Professions Code): Address v
❑ I, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). _ .
—11
CONSTRUCTION LENDING AGENCY �
® k,— 5 G 51!f D
I.hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.). ''�''� 51Z
Lender's Name
Lender's Address l + _
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
above-mentio perty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signat er ittee Date