HomeMy Public PortalAbout5025ALESSANDRO AVE_Plumbing (2) III Z WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
hereby affirm that I have a certificate of consent to self 76A667A _
insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
or a certified cop hereof (Sec. 3800, Lab. C.)
gF4M f �yL✓rl COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished.
FOR APPLICANT TO FILL INPRINT OR TYPE BUILDING
® Certified copy is filed with the county building inspec- ( ) ADDRESS Q 4
tion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY a-
Date —,YflApplicant � `� , r'� WATER.CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars ($100)or less.) MAIL
LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of � 7l✓ /
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR j
Compensation provisions of the Labor Code, you must forth- CIT �� ! G ! TEL. NO.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE p LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION O.N �7 BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS DISTRICT O ^CT N �l
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER IJ
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINALVALIDATION @'
�j�f/p/� DATE rr��
License Number ry/�/7 0 Lic. Class
FINAL
Contractor / f+� �1 Date � '� BY C-3
/^
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❑ I am exempt under Sec. ��
l✓ 1 �,
B.&P.C. for this reason g
Plan check fee ® T
Date: PLUMBING PERMIT ISSUING FEE$ cj -
Signature -
TOTAL FEE i–v r
Plan check applicant I `
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name /K/�" L L
I hereby affirm that I am exempt from the Contractor's License r
Law for the following reason (Section 7031.5, Business and Address
Professions Code): City I Tel. No Z
❑ I, as owner of the property, will do the work and the
structureis not intended or offered for sale (Section
7044, Business and Professions Code). pop
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