HomeMy Public PortalAbout5329 ZADELL AVE_Plumbing_11/1/1991_ ` WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
+ 1 hereby�cfflrm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workors'Compensation Insurance, 76AS67A lul
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.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS
5702455T A�f&
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY p
Date Applicant WATER CLOSET Z.7
NEAREST g�
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCElm
SHOWER OWNER U
(This section need not be completed If the work Involved by MAIL �i G
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS 6 AS Atm
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner �j SINK �� CITY TEL. NO.
so as to become subject to the Workers Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL.NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
�l VALIDATION
DATE
License Number Lic. Class-- C7
FINAL a,
Contractor Date BY pyx
❑ I am exempt under Sec. ®�
BAP.C, for this reason IF
Plan check fee
Date: �
PLUMBING PERMIT ISSUING FEE$ dD
Signature ig
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's LicenseAddress '
Law for the following reason (Section 7031.5, Business and
Prj essions Code): City Tel. No.
J�,J I, as owner of the property, will do the work and the _
v ` structure is not intended or offered for sale (Section ® _
7044, Business and Professions Cade).
ri" 53 _ 00
CONSTRUCTION LENDING AGENCY
.. z_.
I hereby affirm that there is a construction lending agency for ��
the performance of the work for which this permit is issued A. i-t
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address ?•`- i l�l`� v°��
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-mentioned property for Inson purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature oftermiffee r Date