HomeMy Public PortalAbout4902ALESSANDRO AVE_Plumbing (5) WORKERS COMPENSATION DECLARATION CE ce 81 e»A ) APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self (z ea
insure or a certificate of Workers Compensation Insurance or
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
❑ NUMBER FIXTURE OR ITEM • FEE ADDRESS _ L(��
Certified copy is Bled with the county building inspection
department WATER CLOSET LOCALITY
Date Applicant NEAREST
BATH TUB ROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS ,
COMPENSATION INSURANCE SHOWER OWNER
LAVATORY MAIL
(This section need not be completed if the work involved ADDRESS oa��Aw }
by the permit is for one hundred dollars ($100) or less) SIN K
CITY r (�_ TEL
I certify that in the performance of the work for which this DISHWASHER U
permit is issued I shall not employ any person in any manner CONTRACTOR file
so as to become subject to the Workers Compensation Laws CLOTHES WASHER 0
ADDRESS O
Date Applicant SWIMMING POOL RECEPTOR ~
U
NOTICE TO APPLICANT If after making this Certificate of CITY TEL NO a
Exemption you should become subject to the Workers LAWN SPRINKLER SYSTEM STATE LIC CL
Compensation provisions of the Labor Code you must forth LICENSE NO CLASS Z
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked GAS SYSTEM OUTLETS DISTRICT NO PR CESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter L5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi FINAL �_ VALIDATION
ness and Professions Code and m license is in full force and DATE
effect
FINAL
1 `
License Number Lic Class BY 1
Contractor Date \
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051 Bus
ine.s and Professions Code)
TOTAL FEE
Lic or Reg No Date Plan check applicant
HOME OWNER BUILDER DECLARATION Name
�� �
I hereby affirm that I am exempt from the Contractors Address 9{5 5 4,8 A
License Law for the following reason (Section 7031 5 Busi City Tel No ,
ness and Professions Code) ` # a o'0 0 o 5
I as owner of the property am exclusively contracting
with licensed contractors to construct the project 2 0 0 1 2 5 0
(Section 7044 Business and Professions Code) '
'0'0 0 1 2 5 0,F2CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency 0 8 1 0—8 2
for the performance of the work for which this permit is
issued(Sec 3097 Civ C)
Lenders Name
Lender s Addr-ss
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 pro erty f in^p ton purposes
ignature of Permittee Date