HomeMy Public PortalAbout5002ALESSANDRO AVE_Plumbing (3) RK€RS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �7
G,ph o �m that I have a certificate of consent to self 20 0026 DPW 6/87 C I
insure or sf certificate of Workers Compensation Insurance 76A667A ILJII
or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
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Policy '
icy No(6Y79q -ff Company , �?A TE7-/r VIVD
Cep tified copy is hereby furnished
® FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec ADDRESS S ��Z /ES$i A6W
� � NUMBER FIXTURE OR ITEM
tion department _1�dL"�^""^ ® FEE LOCALITY
Date 6-1-89 Appli4ant /'iLt�, l� WATER CLOSET 0 O NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB
CROSS ST
COMPENSATION INSURANCE �G SHOWER OWNER of Ai I'
(This section need not be completed If the work Involved by MAIL a n�
the permit is for one hundred dollars($100)or less) X LAVATORY ADDRESS 00 Z X41 5 I���rW
I certify that in the performance of the work for which this
permit is issued I shall not employ any person to any manner SINKCITY r G TEL NO_V(05-57 7
so as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR v s$C(� 5 ����,e �e fit'
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT If after making this Certificate of ADDRESS
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM CITY �d plppr C t- TEL NO
with comply with such provisions or this permit shall be STATE LIC Lfi
deemed revoked WATER HEATER I LICENSE NO CLASS �J
LICENSED CONTRACTORS DECLARATION DISTRICT NO ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �7 Q
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER (J U
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL VALIDATION di
License Number I q? Lic Class_ DATE
Q
FINAL
Contractor AQS65A '}ate BY 0
❑ ~
I am exempt under Sec (,)
W
B 8P C for this reason t1'
Plan check fee ® Z
Date `
PLUMBING PERMIT ISSUING FEE$ � O
Signature
TOTAL FEE -
SINGLE FAMILY Plan check applicant
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s License Address o
Law for the following reason (Section 7031 5 Business and ? +
Professions Code) City Tel No - - -- 46.501
❑ I as owner of the property will do the work and the
structure is not intended or offered for sale (Section
si
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY �l
j hereby affirm that there is a construction lending agency for 70e�
the performance of the work for which this permit is issued s
(Sec 3097 Civ C )
W YBl
Lender s Name � 4Me
v
Lender s Address 3676 1 AA 8=20
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
above mentioned property for inspection purposes
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SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee f bate<