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HomeMy Public PortalAbout5233ALESSANDRO AVE_Plumbing (2) Ems, -A jNORKER'SCOMPENSATION DECLARATION ` 230026 DPW 9/89 APPLICATION FOR PLUMBING PERMIT I he�'eliy,affirm thet I have a certificate of consent to self insure, 76A667A , or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec. 3800 Lab.C.) • COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 4 F-1 Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM @ FEE ( LOCALITY Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. (A �t BATH TUB COMPENSATION INSURANCE ASSESSOR MAP BOOK PAGE PARCEL (This section need not be completed if the work involved by the SHOWER permit is for one hundred dollars($100)or less.) LAVATORY OWNER 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as toMAIL SINK ADDRESS become subject to the Workers' Compensation Laws. , DISWASHER CITY TEL.NO.�{�6 6'r Date Applicant CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR `; r provisions of the Labor Code, you must forthwith comply with such ADDRESS 5 ?-7- f / provisions or this permit shall be deemed revoked. LAW PRINKLER SYSTEM R 1' LICENSED CONTRACTORS DECLARATION r CITY` J TEL.N0. Vi a" I hereby affirm that I am licensed under provisions of Chapter WATER HEATER a _ STATE LIC. O (commencing with Section 7000) of Division 3 of the Business and_ GAS SYSTEM OUTLETS LICENSE NO.l /" ��''` CLASS 0Professions Code, and my license is in full force and effect. OUTLETS OVER DISTRICT NO. RO ESSED BY cc ,f y� 5 PER SYSTEM Q License Numb e VLic.Class / FINAL DATE _ f'1, V LIDATION W Contractor Date 11 co ❑ I am eFINAL Z xempt LIS, BY B.&P.C.for thisr son Plan check fee , Signature PLUMBING PERMIT ISSUING FEE$ Q ❑ TOTAL FEE 3O Plan check applicant SINGLE FAMILY - HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law m'`=' 47 for the following reason (Section 7031.5, Business and Professions Address `_sV Code): - ❑ City Tel. No. 1 -f- I, as owner of the property,will do the work and the structure F_ is not intended or offered for sale (Section 7044, Business T±-i;`I and Professions Code). - 3� CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the Ut performance of the work for which this permit is issued (Sec. 3097, Civ.C.) Lender's Name 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 I s regulating Plumbing, and hereby authorize represent at' sof this County o enter upon the above-mentioned property f s ction purp s. _© SEE REVERSE FOR EXPLANATORY LANGUAGE J Sig ature of Pe'mi tee Date