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HomeMy Public PortalAbout4839ALESSANDRO AVE_Plumbing (2) *VORKER$' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT 20-0026 DPW 4/87 i hereby, affirm that I have a certificate of consent to self in- 76A667A surerfor a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) ' certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING Certified❑ Certified copy is filed with the county building inspection ADDRESS (43 L,S55A ^D ST, department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY WATER CLOSET(TOILET) Date Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER • lu ",sr1,VA D&IJ& (This section need not be completed if the work involved by MAIL r �} the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS G JAA401'q D '►f`✓ I certify that in the performance of the work for which this per- SINK mit is issued, 1 shall not employ any person in any manner soKitchen, -U Yd1 ab CITY CATIA C TEL. NO. as to become subject to the Worker�Cpensation' Laws. DISHWASHER CONTRACTOR Date 3 Applicdq{,� - _ CLOTHES WASHER NOTICE TO APPLI ANT:.If, after making this Certificate of Ex- ADDRESS tion, you should become subject to the Workers'Com en- SWIMMING POOL RECEPTOR em P Y I P CITY TEL. NO. lotion provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I•am licensed under provisions of Chapter GAS SYSTEM OUTLETS �, © Q� 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER !7 and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION fect. DATE — G License Number Lic. Class `` V FINA 1 99 Contractor Date BY ` I`" - p ❑ _s 2 �i U I am exempt under Sec. .`.i a .l Nsd B.BP.C. for this reason Plan check fee r _� :tel •^',_ ".i a. 'e.." Date: Poo PLUMBING PERMIT ISSUING FEE$ 16 Signature TOTAL FEE 51( SINGLE FAMILY 'HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and st' r'_"ti'r`== _i Professions Code): Address a•.. .. � H�M7.i..t�.+alt, I,tas owner of the property, will do the work and the City Tel. No. structure is not intended or offered for sale(Section 7044, Business and Professions Code). , CONSTRUCTION LENDING AGENCY I 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 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 representatives of this County to enter upon the above- entioned p operty for inspection purposes. /� SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Permittee Date