HomeMy Public PortalAbout5426 ACACIA ST_Plumbing_9/10/1992_tub, water heater, gas system WORKER'S COMPENSATION DECLARATION 76A6620 0026 9/89 _ APPLICATION FOR PLUMBING PERMIT
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I hereby affirm ;hat I have a certificate of consent to self insure, r�
or a cdrtrficate of Worker's Compensation Insurance, or a certified
copy tnereof'(Sec 3800 Lab C) A , - i 1 ! 11
9 r
COUNTY OF LOS ANGELES 4 'DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV
Policy No j Company �i�9?� �Y'✓�'
Certified copy-is hereby furnished '
' ti FOR APPLICANT TO FILL IN(PRINT OR TYPE) - _ BUILDING
Certified copy is filed with the county building inspection ' a ADDRESS Z Q e4
departLOCALITY,
meht _ �' �+ NUMBER FIXTURE OR ITEM Q FEE 1 l
Date g �Jf gy Applicant- � WATER CLOSET -�1/ r cry�j 4 ►� / L� .
NEAREST
n it
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 1 CROSS ST - `j r7Q 1-J W
'COMPENSATION INSURANCE , �+ «/ ASSESSOR
(This section need not be completed if the work involved,by the SHOWER( MAP BOOK, r PAGE PARCEL
permit is for one hundred dollars($100)or less). OWNER '
I certify that m work for which this permit the performance of the
LAVATORY 1JjL* ASL I G is no/ f'
is issued, I shall not em to an ' MAIL ` d
p y y person in any manner so as to SINK _ ADDRESS
become subject,to the Workers'Compensation Laws �
_ g DISWASHER ' a CITY TEL-NO ,
Date A ` Applicant CLOTHES WASHER I '
NOTICE TO APPLICANT If, after makin this,Certificate of CONTRACTOR
s
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR, O
provisions of the Labor Code, you must forthwith comply with such1 1 ADDRESS
provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM `
i LICENSED CONTRACTORS DECLARATION I CITY��m L—J`�Y TEL NO�
I hereby affirm that I am licensed under provisions of Chapter 9 �' WATER HEATER O
STATE LIC
(commencing with Section 7000) of Division 3 of the Business and I GAS SYSTEM OUTLETSLICENSE NO ��'� �� CLASS
Professions Code,and my license is in Will force and effect V
OUTLETS OVER { DISTRICT NO PROCESSED BY
5 PER SYSTEM • _ � G �
License Number e, L72-7 Lic Class �� ► O I—
J FINAL s VALIDATION �t/ {' W.
.. Contractor - "'i[,� '`�'Dated 'DATE t ���(1 �1 p- Lfj ��_� Y 7f 1�; ,CL
�
Y FINAL �` ✓ w a�? Z
I am exempt under Sec BY �iq 2_ �
R�.: t n8..
B RPC for this reason -x ' $
Plan check fee _ " `
Date _ PLUMBING PERMIT ISSUING FES$ ® 3307 '
Signature��,���
' TOTAL FEE �� _i ITEMS '
SINGLE FAMILY 40
Plan check applicant r TOTAL s s ;
= [ n
HOME OWNER-BUILDER DECLARATION. _ Name } }�• Ct�,.4V
1 hereby affirm that I am exempt from the Contractor's License Law '' tt '•� ' fw r -' z ' ffy
for the following reason (Section 7031 5, Business and Professions t Address.-, f „ v y ' CHANGE .,[1
Code) !
,i
_ City p �, _ Tel;No
I, as owner of the property, will-do t(e work and the structure , �i f�
is not intended or offered for sale Section 7044, Business _ V i 1 I
and Professions Code) �` t "
a'
,.. ' Poo ark S:
CONSTRUCTION LENDING AGENCY
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) )
Lender's Name _ t - r
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 ordinances
and,State laws regulating Plumbing,'and hereby authorize-- t
representatives of this County to enter upon the above-mentioned
property for pection purposes - SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date y ,