HomeMy Public PortalAbout4942ALESSANDRO AVE_Plumbing (2) � s WORKERS' COMPENSATION DECLARATION
6 DPW 4/87 APPLICATION FOR PLUMBING PERMIT
♦" t hereby, affirm that I halve a certificate of consent to self in- 76A667
sure, or a certificate of Workers'Compensation Insurance,or a CE 8116(REV. 8/86)
certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WOR
Policy No. Company
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
❑ Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
WATER CLOSET (TOILET)
Date Applicant a NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE / SHOWER OWNER
jf(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) ` LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK _ CITY t „f n TEL. NO. -
mit is issued, I shall not employ any person in any manner so _ ` y n>>t� y w
as to become subject to the Workers'.Compensation Laws. DISHWASHER
CONTRACTOR
Date '`f -/'~ A licani s1 CLOTHES WASHER
NOTICE TO APPLICANT: If,pafter making this Certificate of Ex- f SWIMMING POOL RECEPTOR ADDRESS
emption,you should become subject to the Workers'Compen- a-'=
CITY G TEL. NO.
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS r i
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER d
fed Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL J VALIDATION V
DATE
License Number Lic. Class W
J
FINAL LL
Contractor Date BY 4L. }
❑ I am exempt under Sec. a
Q
B.&P.C. for this reason Plan check fee ► IL
Date: PLUMBING PERMIT ISSUING FEE$ W
Signature TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant • x
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and
Professions Code): Address
W I, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044,
Business and Professions Code), Poo.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 and state that the
above information is correct. I agree to comply with all County ,
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date