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HomeMy Public PortalAbout5008ALESSANDRO AVE_Plumbing (2) WORKERS' COMPENSATION DECLARATION APPLICATION FOR-PLUMBING PERMIT 20-0026 DPW 4/87 I hrsreby,affirm thc>d I_hai�jl. certificate of c ant to self in- 76A667A S r ox o.certificate of Workers'Com19e1NSatioo nsurance, or a CE 817(REV. 8/86) Cied copy thereof (Sec. 3800, Lab. C.) Po'4,icy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC.WORKS ❑ .Certified copy is hereby.furnished. copy y p FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDADDRESS 6 J, Certified co is filed with the count buildinginspection ADDRESS ��J department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY t Date Applicant WATER CLOSET(TOILET) 00 NEAREST ( + , CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB '® CROSS ST. J(4 LG 1 COMPENSATION INSURANCE SHOWER OWNER 1� ( (This section need not be completed if the work involved by MAIL 1 the permit is for one hundred dollars ($100)or less.) LAVATORY 1 ADDRESS ()DG � lr_ I certify that in the performance of the work for which this per- SINK !��l 1 /_ �p� J 10'� mit is issued, I shall not employ any person in any manner so CITY 1 J Gf N TEL. NO. 2 as to become subject to the Workers Compensation Laws. DISHWASHER OV CONTRACTOR Date Applicant � � CLOTHES WASHER � ADDRESS NOTICE TO APPLICANT: If, after making this.Certificate of Ex= SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- CITY TEL. NO. J s�3�y 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. C SS LICENSED CONTRACTORS DECLARATION © DISTRICT NO. Ci } v 1 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 and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL feet. VALIDATION License Number LIC. Class DATE Q_ 0 O U FINAL // Contractor Date BY ��'� O U I am exempt under Sec. � 6.8P.C. for this reason Poo.Plan check fee g Date: PLUMBING PERMIT ISSUING FEE $ • Signature ? TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name _ r C�i 1 t 5 Law for the following reason (Section 7031.5, Business and T g Prof sions Code): Address 'O r� ACCs AV � �� ���'� 3307 �.;� Cdr I, as owner of, the property, will do the work and the City �,a `)tr- Tel. No. '�°'' structure is not intended or offered for sale(Section 7044; i ITEMS 'Business and Professions Code). ► � �� t1 • CONSTRUCTION LENDING AGENCY ' ICIA� 2© -tee I hereby affirm that there is a construction lending agency for CHECK 52°50 the performance of the work for which this permit is issued CHANGE ° (Seca 3097, Civ. C.).' 00 Lender's Name MrWO1 x/26/, Lender's Address 5q�1 i A�f11��q 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-me do ed proper for inspection purposes. .. � , l� �� '�✓�_ � SEE REVERSE FOR EXPLANATORY LANGUAGE Signature ol Permittee VDate