HomeMy Public PortalAbout5048ALESSANDRO AVE_Plumbing (2) '• WORKERS' COMPENSATION DECLARATION 20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT
+i PrP affirm that I have a certificate of consent to self in- r^�
76A667A
sure,o a certificate ot Workers'Compensation Insurance,ora CE 817(REV. 8/86) lul
ceifified copy thereof (S,ec. 3800, Lab. C.
COUNTY OF LOS ANGELES DEPT-.'.,OF PUBLIC WORKS-`
Policy No. Company
FCertified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS Jrd � �
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant WATER CLOSET(TOILET)- NEAREST
BATH TUB CROSS ST.., w
CERTIFICATE OF EXEMPTION FROM WORKERS' v,
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less:) 4f LAVATORY �l ADDRESS
I certify that in the performance of the work for which this per- SINK CITY TEL. NO �Z� Z
mit is issued, I shall not employ any person in any manner so U
as to become subject to the Workers C pensafion Laws. DISHWASHER
CONTRACTOR
Dat 8 Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after ma ' g this Cer icate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the'Workers'Compen- CITY TEL. NO.
cation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESS 'BY
I hereby affirm that I am licensed under provisioris of Chapter
GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER t t
and Professions Code, and my license.is in full force and ef- 5 PER SYSTEM FINAL LIDATION
fect. DATE
License Number Lic. Class
U
AB
Contractor Date O
t—
V
0 I am exempt under Sec. 2 9Ll4 7 A LU
B.&P.C. for this reason co
Plan check fee ► # o o o o 5
Date: PLUMBING PERMIT ISSUING FEE$ ) o o 2 a 5 0
Signature
TOTAL FEE
SINGLE FAMILYo o o '2 x 5 0 5
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name2 7 '-8 8
Law for the following reason (Section 7031.5, Business and
Professions Code): Address
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).
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
ab ve-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si oture of Pe itee Date