HomeMy Public PortalAbout4905ALESSANDRO AVE_Plumbing (2) ' WORKERS COMPENSATION DECLARATION 76A617A
I hereby affirm that I have a certificate of consent Jo self w cq 917 (z eq) - APPLICATION FOR PLUMBING PERMIT
insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNoj4jC--9—CL9_CL3Company wpst American
Certified copy is hereby furnished FOR APPLICANT 77FILL IN (PRIN OR TYPE) BUILD&G
ADDRESS r' �
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE
epa t en WATER CLOSET LOCALITY
Date 1— r'— ApplicantUni Versal Plumb,_n,; NEAREST J
BATH TUB CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS —
COMPENSATION INSURANCE SHOWER OWNER
LAVATORY MAIL
(This section need not be completed if the work involved f ADDRESS >
by the permit is for one hundred dollars ($100) or less) SINKa
CITY 4905 Alessandro Ave Temple wtv O
I certify that in the performance of the work for which this DISHWASHERU
permit is i,sued I shall not employ any person in any manner CONTRACTOR cc
so as to become subject to the Workers Compensation Laws CLOTHES WASHER0
ADDRESS
Date Applicant SWIMMING POOL RECEPTOR 2631 Lee Ave
W
NOTICE TO APPLICANT If after making this Certificate of CITY TEL N?57 _ d
Exemption you should become subject to the Workers LAWN SPRINKLER SYSTEM STAT LIC N
Compensation provisions of the Labor Code you must forth WATER HEATER LICENSE NO CLASS Z
with comply with such provisions or this permit shall be
deemed revoked GAS SYSTEM OUTLETSTRICT OSSED Y
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division`3 of the Busi FINAL VALIDAT
ness and Professions Code and my license is in full force and DATE "1 -L��p,
effect 111111 ((
License Number 38667$ic ClassC36 BY AL dk f P4
ConUTgtpa7Arca1 PlttmbDatel_77_8 v _CirtCcj
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 ����
mess and Professions Code) TOTAL FEE
_S
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 City Tel No
ness and Professions Code) ;93856A
I as owner of the property am exclusively contracting
with licensed contractors to construct the project # 0 0 o e o Jr
(Section 7044 Business and Professions Code) 2 0 o 1600
CONSTRUCTION LENDING AGENCY o a 0 1 6,0 0 5
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is v 0 1 2 3—8 1
issued(Sec 3097 Civ C)
Lender s Name
i
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 entioned property for inspection purposes
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Signature of P r tte Da