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HomeMy Public PortalAbout5042ALESSANDRO AVE_Plumbing (2) r � I WORKERS' COMPENSATION DECLARATION APPLICATION' FOR PLUMBING PERMIT I hereb;t affirm that I have a certificate of consent.to self in- 20-0026 DPW PW 4/87 r `1 4cure`or a certificate of Workers'Compensation Insurance,oro CE 817(REV. 8/86) cer�jg�_cQ�y �Ses 3800, Lab. C.) IIIXXX... 1'�']N�J"�, /`"��� COUNTY LOS A GELES DEPT. OF PUBLIC WORKS Po icy o. ompany Certified copy is hereby furnished. MNN AZQA FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING Certified copy is filed with the county bull g ins ction ADDRESS departmen NUMBER FIXTURE OR ITEM @ FEE LOCALITY WATER CLOSET(TOILET) Date Applicant NEAREST CERTIFICATE OF EXEMP OM 5' O RBATH 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 ($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK mit is issued, I shall not employ any person in any manner so CITY EL. NO. as to become subject to the Workers' Compensation Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR 1,5 emption, you should become subject to the Workers'Compel CITY TEL. NO.'� sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC. !:�0 ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM. OUTLETS ✓` 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER 1J and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION fect. DATE License Number O 1 Lic. Class-`=yl�. '. U ^ FINAL Contractor e d BY z 9 5 A 0 I am exempt under Sec. U '# O O O 10 O 5 UJI B.&P.C. for this reason ► try Plan check fee ;Io 6.1650 Date: PLUMBING PERMIT ISSUING FEE$ Signature 'o o o.1 6 5 0.55 TOTAL FEE SINGLE FAMILY jo 5. 0 Q d 8 8 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 i Professions Code): Address r I, as owner of the property, will do the work and the City Tel. No. structure is not intended or offered for sale(Section 7044, Business and Professions Code). J CONSTRUCTION LENDING AGENCY. I hereby affirm that there is a construction lending agel for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address 1 certify that I have read this application and state that the oil.above information is correct. I agree to comply with all County ordinances and ate laws regulating Plumbing, and hereby authorize re ent es of this County to enter upon the above-me ne perty for inspecti n purposes. Q', SEE REVERSE FOR EXPLANATORY LANGUAGE r tee Ate