HomeMy Public PortalAbout5233ALESSANDRO AVE_Plumbing (3) OR f ERS COMPENSATION DECLARATION 7 iI WORKERS
t3rnthat I have a certificate of consent to self C9 81n z eoI APPLICATION FOR PLUMBING PERMIT
insure or a certificate of Workers Compensation Insurance or 7—, _
a certified copy thereof(Sec 3800 Lab C) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
❑ ADDRESS
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM � FEE
department WATER CLOSET LOCALITY
Date Applicant I NEAREST
r CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
COMPENSATION INSURANCE 1 SHOWER OWNER
(This section need not be completed if the work involved 2, LAVATORY MAIL ADDRESS '— �, >-
61-
by the permit is for one hundred dollars ($100) or less) SINK CITY L NO O
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1 certify that in the performance of the work for which this DISHWASHER X
permit is issued I shall not employ any person in any manner CONTRACTOR O
so as to become subject to the Workers Compensation Laws CLOTHES WASHER ADDRESS ~
U
Date Applicant SWIMMING POOL RECEPTOR LU
0-
NOTICE TO APPLICANT If after making this Certificate of CITY TEL NO
Exemption you should become subject to the Workers LAWN SPRINKLER SYSTEM Z
STATE L I C
Compensation provisions of the Labor Code you must forth WATER HEATER LICENSE NO CLASS
with comply with such provisions or this permit shall be
deemed revoked GAS SYSTEM OUTLETS DISTRICT NO PRO ESSED BY
L /�� r
LICENSED CONTRACTORS DECLARATION OUTLETS OVER ✓
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi FINAL w l VALIDATION
ness and Professions Code and my license is in full force and DATE r �p (,
effect
License Number Lic Class FINAL
BY
Contractor Date
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051 Bus PLUMBING PERMIT ISSUING FEE$
iness and Professions Code)
TOTAL FEE 1 91
Lic or Reg No Date Plan check applicant ~
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractors Address
License Law for the following reason (Section 7031 5 Busi Cit Tel No �3 4 2 4 A
ness and Professions Code) y i
0 0 0 0 0 5
® I as owner of the property am exclusively contracting
with licensed contractors to construct the project 2 0 0 1 9 0 0
(Section 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency 1 215-80
for the 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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
above mentioned property for inspection purposes
S gnatur of Permittee Date
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