HomeMy Public PortalAbout5043ALESSANDRO AVE_Plumbing (4) WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have o certificate of consent to self in 20-0026 DPW 4/87
sure,or a certificate of Workers'Compensation Insurance,ora 76A667ACE 817(REV. 8/86)
certified copy thereof (Sec. 3800, lab. C. COUNTY OF LOS'ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Fj Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING �'O ti`
Certified copy is filed with the county.building inspection ADDRESS � / {�4—
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY /j /f .-k
Date Applicant / WATER CLOSET(TOILET) NEAREST C �!
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST. Q C e
COMPENSATION INSURANCEOWNER * F
SHOWER' _
(This section need not be completed if the work involved by MAIL
the permit is For one hundred dollars ($100)or less.) LAVATORY d ADDRESS PSro �
I certify that in the performance of the work for which this per- SINKr
mit is issued, I shall not employ any person in any manner so CITY �6-' L' TEL. NO,
as to become subject to.the Workers' Compensation taws.. DISHWASHER
- CONTRACTOR
Date
-
Date Applicant . �Y
ADDRESS,
NOTICE TO APPLICANT: If, after making this'Certificate of Ex-
emption, you should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permitshall be deemed revok- STATE LIC.
ed. WATER.HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter / GAS SYSTEM OUTLETS ��
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINALVALIDATION >"
fect: DATE 3 q r.
License Number Lic. Class O'
FINAL V
Contractor Date BY0
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I am exempt under Sec.
B.&P.C. foe this reason ►
0.
_ Plan check fee - g
Date: PLUMBING PERMIT ISSUING FEE$
Signature
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SINGLE FAMILY TOTAL FEE
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name 4 eh "s
Law for the following reason (Section 7031.5, Business andel
n^nLiti,:-
Professions Code): Address * 'Ve
I, as owner of the property, will do the work and the City. e CAW Tel. NoZ&!;_-r7
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structure is not intended or offered for sale(Section 7044, v 1 I^hS
Business and Professions Code). -^=s •rx c-+-
CONSTRUCTION LENDING AGENCY �'{ Hi sf
I hereby affirm that there is a construction lending agency for �` / U.
the performance of the work for which this permit is issued s
(Sec. 3097, Civ. C.): -fs • '-r
Lender's Name t ie;
Lender's Address. ac
82,.s
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
authori a representat' es of thi C unty to enter upon the
abov mentio d rop for ' sp coon rposes,
Z/" SEE REVERSE FOR EXPLANATORY LANGUAGE
gat a Vf-Permi Date