HomeMy Public PortalAbout4905ALESSANDRO AVE_Plumbing (3) I
WORKERS COMPENSATION DECLARATI7F. 76A¢87A
I hereby affirm that I have a certificate of consent to self CE e17 (z ao( APPLICATION FOR PLUMBING PERMIT
insure or a certificate of Workers Compensation Insurance or
ace if copy thereof(Sec 3800 Lab C COUNTY OF LOS ANGEL �S BUILDING AND SAFETY
Pohc __�=��C niy ��
Certif d copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING /f p
ADDRESS E
ertified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM FEE a
department LOCALITY CE—'Gfi
WATER CLOSET
Date Applicant NEAREST
BATH TUB CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE SHOWER OWNER
RY MAIL
LAVATORY(This section need not be completed if the work involved LADDRESS 0
by the permit is for one hundred dollars ($100) or less) SINK1
CITY �^� Cl TEL NO 6
I certify that in the performance of the work for which this DISHWASHER
permit is issued I shall not employ any person in any mannerCONTRACT0R�NIllel
so as to become subject to the Workers Compensation Laws CLOTHES WASHER
ADDRESS 0 g� `i � � O
Date Applicant SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT If after making this Certificate of CITY �� �� TEL NO rl, -j4L W
Exemption you should become subject to the Workers LAWN SPRINKLER SYSTEM STATE �/ 7 LIC / W
Compensation provisions of the Labor Code you must forth LICENSE NO l� p CLASS C t, z
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked ' GAS SYSTEM OUTLETS DISTRICT NO
R E SED B
LICENSED CONTRACTORS DECLARATION OUTLETS OVER �QO
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi FINAL VALIDAT N
ness and Professions Code and my license is in full force and DATE -L�
effect
FINAL ��
License Num Lie Class v `� �✓ BY
Contract Date r '
I am exempt from the licensing ements as aa Plan check feed
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ �(1�
acting in my professional capacity (Section 7051 Bus
metes and Professions Code)
TOTAL FEE (f/
Lie 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)
I as owner of the property am exclusively contracting
with licensed contractors to construct the project 9 4 4 0 4 A
(Section 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY Z ° ° 1000
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is 10005
issued(Sec 3097 Civ C)
Lender s Name
4 0316-81
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 eprese' 'Ives f this County to enter upon the
above ioned cope f rinspection purposes
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Signature ot ge7rmittee Date
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