HomeMy Public PortalAbout5043ALESSANDRO AVE_Plumbing (5) WORKERS' COMPENSATION DECLARATION Z 20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT
I here, affirm`ih'9ftl have a certificate of consent to self in 76A667A
sure, or a,certificate of Wprkers'CoMpLnsation Insurance,or a CE 817(REV. 8/86)
certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS � �
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant WATER CLOSET(TOILET) O
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' _ _ BATH TUB B. 1 05
CROSS ST.
COMPENSATION*INSURANCE OWNER �`/ /�`
SHOWER / L'J ` 7'
(This section"need not be completed if the work involved by MAIL
_ ,^/�t ►+ r f
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRES�O J1 ,4771J���/.1� V
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so SINK CITY !1 TEL. NO. 'S
as to become subject to the Workers"Compensation Laws. DISHWASHER C
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after.making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly'with such provi'si'ons or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DI TR T r� PROCE Y
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS f ((
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
q 5
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINALVALID TION
fect. DATE
License Number Lic. Class O
FINAL U
Contractor Date BY 0
O
.Lam exempt under Sec. V
W
B.&P.C. for this reason ►
-Plan check fee. �
Date: PLUMBING PERMIT ISSUING FEE$ 13
Signature TOTAL FEE 01/111
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION5
I hereby affirm that I am exe_mpt from the Contractor's License Name-
Law for the following reason (Section 7031.5, Business and al.�Tag
Professions Code): Address 330��17 106 '
-
1, as owner of the property, will do the work and the City Tel, No. ITEMS
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). ► TINA` 80 m 50
CONSTRUCTION LENDING AGENCY CHUCK 60.5173
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued t; A�'G e�Fl
(Sec. 3097, Civ. C.).
Lend'er's Name C� L0 s?i
.+ter �f•f L
Lender's Address863
f 1 A M I 0'''
1 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 regjq1uting Plumbing—and hereby
auth ize representatives of s County to enter upon the
abo -men oned ty fi r in pection urposes_.
SEE REVERSE FOR EXPLANATORY LANGUAGE
g a e 'f rrrit a Date