HomeMy Public PortalAbout4848ALESSANDRO AVE_Plumbing (2) _,VRKERS COMPEN�TI.9;v?DECLARATION APPLICATION FOR PLUMBING PERMIT
r4. affirr�T that I have a certificate of consent to self 76A667A
insure Or a cert9icare of Workers Compensation Insurance CE 817(REV 10/81) 'fl
or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished BUILDING (� a's c /�
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS '/ 0 Z O e -�S� �' /�b
Certified copy is filed with the cm
ounty building spec T
tion department NUMBER FIXTURE OR ITEM @ FEE LOCALITY 1
Date Applicant (� WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST L 6 w CO 4 Z Iq
COMPENSATION INSURANCE SHOWERJI OWNERTam ex 13i25'
(This section need not be completed if the work involved by (1 MAIL
the permit is for one hundred dollars ($100)or less ) f LAVATORY /
ADDRESS /P-{SdIL ,4 D
1 certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner / SINK CITY �C P j� TEL NO 7 e
so as to become subject to the War rs Compensation L s DISHWASHER
CONTRACTOR
Date Applica CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If fter along this Certificate of
Exemption you should b co subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of Labor Code you must forth LAWN SPRINKLER SYSTEM CITY TEL NO
with comply with such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION O DISTRICT NO� P OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER a
and Professions Code and my license is to full force and effect 5 PER SYSTEM FINAL r 1
9 LIDATION
DATE i�G p}
License Number Lic Class t0
FIN U
Contractor Date BY
I am exempt under Sec
U
B 8P C for this reason W
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Plan check fee ® N1
Dat
PLUMBING PERMIT ISSUING FEE$ Z
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Name PX a• / 6 7 a 6 A
I hereby affirm that I am exempt from the Contractor s Licen a
Law for the following reason (Section 7031 5 Business and Address PS 7 G ti��D #t o 0 0 0 0 5
Professions Code) Tel No Z�� + )( 0
- 4650® I as owner of the property will do the work and the
structureis not intended or offered for sale (Section
7044 Business and Professions Code) o -,- 46500
CONSTRUCTION LENDING AGENCY OIL 02 c 8 7
I hereby nffirm 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 00.
ordinances and State laws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
a ove mentioned property for inspection purposes
G SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date