HomeMy Public PortalAbout5043ALESSANDRO AVE_Plumbing (6) WORKERS'COMPENSA20-0026 DPW 4/87 TION DECLARATION APPLICATION FOR PLUMBING PERMIT
I�kereby, affirm that { have a certificate of consent to self in- 76A667A
sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) .
certified`copy'thereof (Sec. 3800, Lab. C.
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Polity No. _ Company
7' .Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING a�/12 n j�c�nL ��
Gertified copy is filed with the county building inspection ADDRESS. '•- -3 r(t J 1.
NUMBER FIXTURE OR ITEM LOCALITY
department. @. FEE
WATER CLOSET(TOILET)
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROMWORKERS' BATH TUB _ CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER 0
(This section need not be completed if theWorkinvolved by
the-permit is for one hundred dollars ($100)'or less.) LAVATORY, ADDRESS
I certify that'in the performance of the work for which this per- SINK Tern 1 TEL.
Q
mit is issued, I shall n'ot employ any person in any manner so - -
CITY I NO. -
as to become subject to the Workers' Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER O
ADDRESS
NOTICE'TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
'emption, you should become subject to the Workers'Compen- CITY TEL. NO.
LAWN SPRINKLER S ,
sation provisions of the Labor Code, you must forthwith comp- CITY
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS ��
9'(comme6cing with Section 7000)of Division 3 of the-Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
feet.
License Number Uc. Class DATE f O 9 O
V
FINAL
Contractor Date BY O
- t-
I'am exempt under Sec. LU
B.&P.C. for this reason pop.Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ 40
Signature `-
-TOTAL FEE
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION pp
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and I
. . ,•rr
Professions Code): Address' _ r„
n;7 y3 i_t
� Cit Tel. No. „ '
IVI 1, as owner of the property, will do the work and the Y
structure is not intended or offered for sale(Section 7044, ? 1 FMS
Business and Professions Code).
1"!0. - a.....9 m
Poo
CONSTRUCTION LENDING AGENCY + ? �tE,fr , Ii
I hereby affirm that there is a construction lending•agency for
the performance of the work for which this permit is issued r• 'z-1.-- i;3
(Sec: 3097, Civ. C.). 5H�=�� `,.i•»
s
Lender's Name
0000-000 a i s t i
Lender's Address
�€r s„F
it i FSM 9:0r,
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-me tioned property for inspection urposes.
t� . �r ) 9/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of� rmittee Date