HomeMy Public PortalAbout4832ALESSANDRO AVE_Plumbing (5) WORKERS' COMPENSATION DECLARATION2026 APPLICATION FOR PLUMBING PERMIT n
I hereby, affi m that I have a cerlficate•of consent to self in- 76A667A FW 4/87 `7 I
sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) IUI
certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished.:. BUILDING i
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE.OR ITEM . @ FEE LOCALITY
/ WATER CLOSET(TOILET)
/ Ssrrp � T`
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM'WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE , OWNER /i✓y
/45rl/0
(This section need not be completed if the wSHOWER D13Z2
ork involved by MAIL
the permit is for one hundred dollars ($100)or less.) I LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK � o
mit is issued, CITY TEL
shall not employ any person in any manner so . NO. .3�p7u
as to become subject to the Workers'Compensation Laws. DISHWASHER /
. CONTRACTOR p
Date Applicant CLOTHES WASHER U�-
NOTICE TO APPLICANT: If, after making this.Certificate of Ex-- ADDRESS
u Workers' en-
em tion, oshould become subject to the Works'Com SWIMMING POOL RECEPTOR
p y I p CITY TEL. NO.
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT ISSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS vSl
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER 6
fed Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL ALIDATION
DATE O
License Number Lic. Class U
FINAL
I�
Contractor Date BY O
a-
I am exempt under Sec.
B.&P.C. for this reason Poo.Plan check fee
Dater PLUMBING PERMIT ISSUING FEE$,
Signature -
TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION
Plan check applicant
I hereby affirm that I am,exempt from the Contractor's License NameJL
Law for the following reason (Section 7031.5, Business and ACCT°v
Professions Code): Address
307 °50
I, as owner of the property, will do the work and the City Tel, No. 1 ITEMS _
structure is not intended or offered for sale(Section 7044, to
Business and Professions Code). pop. TOTAL 34 .20
CONSTRUCTION LENDING AGENCY CHECK .34.5L
I hereby affirm that there is a construction lending agency forC.HAHj °CIO
the performance of the work for which this permit is issued .
(Sec. 3097, Civ. C.).
Lender's Name -
01000-0001 10/24/89
Lender's Address 6370 1 AM 987,13
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
abov m tinned opert for inspection urposes..
i - �- E ',4,7V SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of�Permi a Date r