HomeMy Public PortalAbout5740ALESSANDRO AVE_Plumbing WORKERS'COMPENSATION DECy'ARATION APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate.,of consent to self in- 20-0026 DPW 4/90
76A667A
sure,or a certificate of Workers'Compr?isationitinsurance,or a
certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company COUNTY OF LCIS-ANGELES/ S DEPT. OF PUBLIC WORKS hull
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING rr-
Certified copy is filed with the county building inspection ADDRESSoy a� Q
department. NUMBER FIXTURE OR ITEM. @ FEE LOCALITY /—
Date Applicant WATER CLOSET(TOILET) NEAREST e� W
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by MAIL �L
the permit is for one hundred dollars (;100)or less.) ' LAVATORY ADDRESS Jai-a�7
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CITY TEL. NOD`
as to beco a subject to the Workers'Compensation LqWs. DISHWASHER
Dat Applicant •�I� CLOTHES WASHER CONTRACTORADDRESS.
NOTI E TO APPLIC NT: If, after ma ng this Certificate of Ex-
SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITYTEL.
cation provisions of the Lab+srCode, you must forthwith comp- LAWN SPRINKLER SYSTEMS
C,/
ly with such provisions or this permit shall be deemed revok- STATE i !/ LIC.
ed. ATER HEATER LICENSE NO. G CLASS G3 Y
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter -GASSYSTEM OUTLETS n
9(commencing 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
fect. �i ry �9< / HOSE BIB DATE
License Number_,i �n Lic. Class O
t S� FINAL 0
Contractor Dates BY0.
g
I am Xempt under Sec.
B.BP.C. for this reason ► LU
Plan check fee.
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and H*_-•i os
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, f~=
Business and Professions Code). ► U1 A"
-r•�•;s
CONSTRUCTION LENDING AGENCY ;~;)_�
I hereby affirm that there is a construction lending agency for i t.- -
the performance of the work for which this permit is issued -4 !='s
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address "Yc ' f-11T7 yz
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 ntied B 6p r for inspection Pur sec. '
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signat re f Permittee Date