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HomeMy Public PortalAbout4941ALESSANDRO AVE_Plumbing (4) WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A insure or a certificate of Workers Compensation Insurance CE 817(REV 8/86) �J or((a ccer}ified cop thereof (Sec 38000LLob C ) T., Pol cy No O Company , ' `''N� COUNTY OF LOS,ANGELES DEPT OF PUBLIC WORKS -,- ti n Certified copy is hereby furnished ( , FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING L 1 ��y� , Certified copy is filed with he county b Id ng inspec ADDRESS tion department NUMBER FIXTURE OR ITEM @ /FEE LOCALITY Date • -L` Applicant WATER CLOSET (� © NEAREST 16 CERTIFICATE OF EXEMPTIO FROM WORKERS BATH TUB CRO55 ST _ Y) 1 COMPENSATION INSURANCE SHOWER OWNER + ' (This section need not be completed if the work involved by b MAIL ) E , the permit Is for one hundred dollars($100)or less ) , LAVATORY ADDRESS �� 5 I certify that in the performance of the work for which this permit is issued I shall not employ any person in any manner SINK CITY M TEL NO so as to become subject to the Workers Compensation Laws i4 A DISHWASHER CONTR V [ G Date Applicant r Q CLOTHES WASHER NOTICE TO APPL7ICANT If after making this Certificate of /, ADDRESS Exemption you should become subject to the Workers �/ SWIMMING POOL RECEPTOR CITY TEL NO Compensation provisions of the Labor Code you must forth i+� LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be i C/ STATE UC ° deemed revoked WATER HEATER LICENSE NO,50gsolCLASS LICENSED CONTRACTORS DECLARATION DISTRICT No PT EDBY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL VALID ION ��+r DATE V License Number�al)< Lic Class 0 �, A' (� " FI ContractoA L�-rw —/"`D"afe B ❑ I am exempt under Sec IL IL B 8P C for this reason , 7 5 4 8 A a U) Plan check fee Date PLUMBING PERMIT ISSUING FEE$ s # o 0 o a 0 5 Signature ` , TOTAL FEE ( o o 2 a 5 0 SINGLE FAMILY Plan check applicant o 0 o 2 a 5 Q 5 HOME OWNER BUILDER DECLARATION Name 0 7 2 8 1-8 7 j hereby affirm that I am exempt from the Contractor s License Address r Law for the following reason (Section 7031 5 Business and Professions Code) City Tel No s _ ❑ I as owner of the property will do the work and the structure is not intended or offered for sale (Section poll t 7044 Business and Professions Code) 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 s (Sec 3097 Civ C ) Lender s Name l Lenders Address Y I certify that I have read this application and state that the above information is correct I agree to comply with all County ordinances and State jaws regulating Plumbing and hereby authorize representatives of this County to enter upon the " o menti a roperty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Stature of Permittee IF Date