HomeMy Public PortalAbout4926ALESSANDRO AVE_Plumbing (3) WORK '20-0026 DPW 4/90
ERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consent to self in-
76A667A
sure,or a certificate of Workers'Compensation Insurance,ora _ ...•.
certified copy(hereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company '
Certified copy is hereby furnished. BUILDING G��c�
FOR APPLICANT TO FILL IN(PRINT OR TYPE) 7 O-Gv
F-1Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant WATER CLOSET(TOILET) w NEAREST J
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK CITY TEL. NO.
mit is issued, I shall not employ any person in any manner so
as to become subject to the Worke Com ensation Laws. DISHWASHER
a
ONTRACTOR r
Date to Applicant CLOTHES WASHER
NOTIC TO APPLICANT: If, after king this'Certific of Ex- ADDRESS iJ
SWIMMING POOL RECEPTOR
emption,you should become su ct to the Workers'Compen- CITYTEL. NO.
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE ) 1n LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRINO. (y��PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS .
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER s
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
fect. HOSE BIB DATE
License Number% ` Lic. Class
FINAL O
Contractor, e Date BY p V
J cc
0.
I am exempt un r Sec. YZ2 O ACCT.ff V
B.BP.C. for this reasonPlan check fee. POO. 3303 Date: PLUMBING PERMIT ISSUING FEE$ O 1 ITEMS g
Signature TOTAL FEE / �e (, TOTAL 107, 80
SINGLE FAMILY Plan check applicant '7.80
HOME OWNER-BUILDER DECLARATION PPliCHECK 10
.
1 hereby affirm that I am exempt from the Contractor's License Name CHANGELaw for the following reason (Section 7031.5, Business and .00
Professions Code): Address
F1 I, as owner of the property, will do the work and the City Tel. No. 0000-0001 2/23/96
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). , 4"3 1 AM10a04
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 arid state that the pop.above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
aorize representatives of this County to enter upon the
a o e-mentio17d prop for i ection po
SEE REVERSE FOR EXPLANATORY LANGUAGE
Ile
oture of Permittee V Date