HomeMy Public PortalAbout5031ALESSANDRO AVE_Plumbing (3) W(}RKER'SCOMPENSATION DECLARATION 7DPW 9/89
6A667AAPPLICATION FOR PLUMBING PERMIT
here*y affirm'th`j I have a certificate of consent to self insure,
or a cer}'ficate of Worker's Compensation Insurance, or a certified
copy the 4of(Sec.3800 Lab. C.)
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
Policy No. Company
Certified copy is hereby furnished. BUILDING
F-1Certified
APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS jCZ
Certified copy is filed with the county building inspection
department. NUMBER FIXTURE OR ITEMQ FEE LOCALITY
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE,/p td PARCELL20�4
permit is for one hundred dollars($100)or less.) OWNER
I certify that in the performance of the work for which this permit If
LAVATORY
is issued, I shall not employ any person in any manner so as toMAIL
SINK ADDRESS ��
become subject to the Workers'Compensation Laws. tWg
p DISWASHER CIT TEL.NO.
Date � '" ! Applicant/ctto
�'d CLOTHES WASHER CONTRACTOR
NOTICE TO APPLICANT: If, aftking th' Certificate of L , "
Exemption,you should become subjhe Wok ers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such17—
ADDRESS
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CI7 TEL.N
I hereby affirm that I am licensed under provisions of Chapter,9 WATER HEATER } 0e' �✓ iL
(commencing with Section 7000) of Division 3 of the Business and STATE LIC.
Professions Code,and my license is in full force and effect. 70 A
GAS SYSTEM OUTLETS LICENSE NO. CLASS V
OUTLETS OVER \ DISTRICT NO. PROCESSED BY cc
3��O 5 PER SYSTEM n P/
License Number Lia Class r �J O '!�G�'� U
FINAL VtA►L 1D�Pmf ION I I I
Contractor Date \ DATE 12: Z Z-�7' I j' __ _i_ IIS
❑ am exempt under Sec. // FINAL __ ;-y ,u y�€Z
(A� BY �- 1 i i Ei t�S
B.&P.C.for this reason f.i.`, ��
Date: Plan check fee , -•tai✓ 38 _ 0
Signature PLUMBING PERMIT ISSUING FEE$ 7� �.•Ht:.�•K `�`�a� I
TOTAL FEEi_)HF'tNG eiur-i
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name on Ii I !-n iii`i si_I,` r''.'
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions Address i Q C+ Ail '*o�t 1
Code): i
❑ City Tel.No.
I, as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). ,
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 i spection p r ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
S ature of Permittee Date