HomeMy Public PortalAbout5031ALESSANDRO AVE_Plumbing (2) ' WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I 'hereby'affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING�jti �js iP N
Certified copy is filed with the county building inspec- ADDRESS (0�/ /r/]"I1J A ,/7
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY r T
WATER CLOSET
Date Applicant NEAREST /J �g
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST. �GfJC� fJ
COMPENSATION INSURANCE OWNER ���
(This section need not be completed If the work Involved by SHOWER
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the ermit is for one hundred dollars $100 or less. MAIL _
P ( ) � LAVATORY ADDRESS Sd�� �
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY ,,,Z:2eC_ (91A/ TEL. NO. � 411y
so as to become subject to the Workers Compensation Laws. DISHWASHERCONTRAC / L^
G �/ TOR
Date _!/ Applicant `�'' v l CLOTHES WASHER
NOTICE TO APPLICANT: If, aft4r making thi Certificate of ADDRESS
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY U�c/«¢ T . NO.���
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE g' LIC.
deemed revoked. WATER HEATER LICENSE NO. S3 Q85 CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS Q
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER Q
and Professions Code,and m license is in full force and effect. 5 PER SYSTEM
3 Y FINAL Z 'I( q �� J VALIDATION
DATE
License NumbeS �O8� Lic. Class � � �.
FIN�- �¢� BY AL 0.
Contractor Date ®:
❑ F=,
I � exempt under Sec. �
B.&P.C. for this reason CLI
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
1 hereby affirm that I am exempt from the Contractor's License Address
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Law for the following reason (Section 7031.5, Business and ;
Professions Code): City Tel. No.
❑ ;�.i1_
I, as owner of the property, will do the work and the i
structure is not intended or offered for sale (Section ® I I t• 50- 50 m50
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY HEE :K
I hereby off irm that there is a construction lending agency for �•t-` iT
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Namei'
Lender's Address _ H Q.-4h
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
ignature of Per ee Date