HomeMy Public PortalAbout5342ALESSANDRO AVE_Plumbing WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to -If 76A667A
insure, or a certificate of Workers' Compensation Insura ce, CE 617(REV. 10/81)
or a certified cop t ereof (Sec. 3800 tab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
P❑ollcy No �' ` r ompan
Certified copy is h reby furni ed.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the co u y nspec- ADDRESS 2�
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALI
Date Applican WATER CLOSET NEAREST /:� Ns
CERTIFICATE OF EXEMPTION FROM WOR S' BATH TUB
CROSS ST. �!
COMPENSATION INSURANCE SHOWER OWNER Cliff
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS t• r,
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY j TEL. NO.o�,
so as to become subject to the Worker Compensatio Laws. DISHWASHER d
CONTRACTOR
Date t a Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making tFils-'Certificate of ADDRESS r'
Atco:- 04
xemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY L'^ TEL. NO:� r/
r
with comply with such provisions or this permit shall be STATE LIC. �I
deemed revoked. WATER HEATER LICENSE NO. � CLASS [
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ZSED IY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER (�
and Professions Code, and.my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
DATE
License Number 9`v C� / Lic. Class ,- ,� g�
--��/ FINAL
Contract_441 Date ��leBY
❑ r�
I am exempt under Sec.
B.&P.C. for this reason v'
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ �yC— 7 /
Signature
TOTAL FEEbb
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License 00 a F
Law for the following reason (Section 7031.5, Business and Address
Professions Code): City Tel. No. c I0 0
❑ I, as owner of the property, will do the work and the 2 Fo o 1 H 5 0
structure is not intended or offered for sale (Section
7044, Business-and Professions Code). - c o r
CONSTRUCTION LENDING AGENCY C L L 4I 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 r presentatives of this County to enter upon the
ab ve- e tioned property f r insp ction purpos
/� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date