HomeMy Public PortalAbout5720ALESSANDRO AVE_Plumbing s WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
-I hereby,affirm,th6t I have a certificate of consent to self 76A667A'
insure, or a certificate 9T Workers' Compensation Insurance, CE 817 (REV. 8/86) `+g� �� Temple (,°$t
or a certified copy-thereof (Sec. 3800, Lab. C.) 2.71 COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. 2619-165CompanySOTg'
Certified copy is hereby furnished.
12 -
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS
ar l
Ave-
tion department. NUMBER FIXTURE OR ITEM @ FEE y
LOCALITY Tee Cit
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DatexA*x* -1 icant General Tnsta_ll WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. Live OakAve.
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars($100)or less.) LAVATORY MA
ADDILRESS Same
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY T
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 6558 West Blvd.
Exemption, you should become subject to the Workers' SWIMMI L RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY a e$ TEL. NO
LAWN SPRINK� YSTEM . 753®254
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER.HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION - kl& 00 DISTRICT NO. ROCESSED BY
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 VAL ION
DATE
License Number 1 5 839 Lic. Class C36699
QS
FIN
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Contractor W-0, )PMV3.n Date 4®55 BY
❑ I am
exempt under Sec. @.
B.BP.C. for this reason
Plan check fee ® g
Date:
PLUMBING PERMIT ISSUING FEE$ 10 5®
Signature
TOTAL FEE
SINGLE FAMILY
Plan check applicant HOME OWNER-BUILDER DECLARATION Name �82 9 A
I hereby affirm that I am exempt from the Contractor's License Address
Law for.the following reason (Section 7031.5, Business and # o o o a o 55
Professions Code): City Tel. No.
❑ I, as owner of the property,.will do the work and the o.. 1 650
structure is not intended or offered for sale (Section
7044, Business and Professions Lode).
CONSTRUCTION LENDING AGENCY o 0 0 1 &cJ OS
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.). 1. 03 m$7
Lender's Name
Lender's Address
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 regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned—prop y fo inspection purposes.
�� SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Permit Da e