HomeMy Public PortalAbout5030ALESSANDRO AVE_Plumbing (2) WOMERS' COMPENSATION DECLARATION 20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT
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1 hereby, affirm that 1 have a certificate of consent to self in- 76A667A �1 I
sure,or a'certificate of Workers'Compensation Insurance, or a CE 817(REV. 8/86) ILJI
certified copy thereof (Sec. 3800, Lab. C.)
2 D 6 • COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy /�rr°-silY '
Certified copy is hereby furnished. 7 -1119a"
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING /) / A�n
Certified copy is filed with the county building inspection ADDRESS /`�L `-} /J'
de art ent. NUMBER FIXTURE OR ITEM @ FEE >>> _
�p � � LOCALITY
Date —l. Z.� Applicant /V/J/ WATER CLOSET(TOILET) NEAREST /6
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST'
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work.involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY D ADDRESS
1 certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CITY TEL. NO.
as to become subject to the Workers' Compensation Laws. DISHWASHER
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CONTRACTOR i' /V
Date ' Applicant CLOTHES WASHER ADDRESS'
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen-• t� � " }
sation provisions of the Labor Code, you must forthwith comp- CITY A/� TEL. NO./ rY,j 0
P Y P- LAWN SPRINKLER SYSTEMG/ (J
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ly with such provisions or this permit shall be-deemed revok- STATE !1[L/ UC. Q��
ed. WATER HEATER LICENSE NO. 7 7 CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I"hereby affirm that I'am licensed under provisions of Chapter GAS SYSTEM OUTLETS O
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER -�O
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION >_
fect. �!Yfb DATE Q.
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License Number Lic. Class ,.V
D FINAL
Contractor / >/yC Date BY
a-
I am exempt under Sec. LU
B.&P.C. for this reason , U)
Plan check fee
Date:y PLUMBING PERMIT ISSUING FEE,$
Signature 1
TOTAL FEE Q(�
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant
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
❑ I, as owner of th6 property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). LI_M�•;
► ? '
CONSTRUCTION LENDING AGENCY ').lsit. s
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued ;_ r,
(Sec. 3097, Civ. C.).-
Lender's Name-
Lender's Wit
Addresss-+-
1s ii_!I f y'. ti
00171 ! s
I certify that I have read this application and state that the a _
above information is correct..)agree to comply with all Count _ __
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes.
x SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date