HomeMy Public PortalAbout5754ALESSANDRO AVE_Plumbing (2) _, '-WORKERS'COMPENSATION DECLARATION 26 APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consent to self in- 76A667A PW 4/87
sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) �,IIL JIII
certified copy thereof (Sec.-7
Sec 500, Lab. C.)
S . ]t4!k_ Ciiu� ' COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
.Policy No, r�2,179 Com pany ,
• Certified copy is hereby furnished. t'
FOR APPLICANT TO FILL IN (PRINT OR TYPE)URE OITEM BUILDING
'r
ISM
WATER CLOSET{TOILET) v�
department. @ FEE
Certified copy is filed with the county building in ection ADDRESS
NUMBER ' FIXTURE LOCALITY ,Cp
�S �� C
Dat,e � Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST. r
COMPENSATION INSURANCE SHOWER OWNER
(This section need riot be completed if the work involved by MAIL ) �
the permit is for one hundred dollars ($100)'or'less.) LAVATORY ADDRESSA
I certify that in the performance of the work for which this per- SINK CITY TEL �7_�3Y
.mit is issued, I shall not employ any person in any manner so . NO.
as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR O f
Date Applicant CLOTHES WASHER C.J�AS (-
�` r
NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDREV4773(/ he SWIMMING POOL RECEPTOR
emption, you should become subject to the Workers'Compen- CITY �� Y .V TEL. N0.33G ZIP
sation 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.3 J v '7 CLASS _ A
LICENSED CONTRACTORS DECLARATION'. DISTRICT / ESS BY
I hereby affirm that I am licensed under,provisions of Chapter GAS SYSTEM OUTLETS (/JeOY
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
fand
e Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL tC- �� V IDATION
DAT. 0
License Number n lO�S�( � Lic. Class V
Contractor l_Yl� l=' '�v�( Date c?? B N O
F-1' I am exempt under Sec. V
�4
B.&P.C:'for this reason ® $6 3 A U)
Plan check fee g
Date: #to o 0 o 0 5
PLUMBING PERMIT ISSUING FEE$
Signature ( 0 0, 650
TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant o o -1650'
I hereby affirm that I am exempt from the Contractor's License Name 218-87
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
1 certify that'I have read this application and state that the Pool
information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorizer preseMotives of is County to enter upon the
above- bone pro rty o inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date