HomeMy Public PortalAbout5757ALESSANDRO AVE_Plumbing (2) .NORKERS'COMPENSATION DECLARATION A ����� �'�� � PLUMBING ������
1 hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished. BUILDING
F-1
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS .57 :5- ' Ile e.c,, / o
Certified copy is filed with the county building inspec-
NUMBER FIXTURE OR ITEM @ FEE
tion department. LOCALITY
WATER CLOSET
Date Applicant NEARECROSS ST, ell (�7
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
Z���GG''�� •7 Q CONTRACTOR �/'/l,�r S
Date A&' CLOTHES WASHER /o ADDRESS _ e
NOTICE TO APPLICANT: If, after making this Certificate of �J l
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY � /vz�p cam TEL. NO. 9�3 �
p p y LAWN SPRINKLER SYSTEM �"
with comply with such provisions or this permit shall be �d STATE ^i LIC.
deemed revoked. WATER HEATER LICENSE NO. I- Os !�" CLASS —
LICENSED CONTRACTORS DECLARATION O DISTRICT NO. PROCESSED BY
1 hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS Q
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION 0.1
License Number
yX S ��� Lic. Class > DATE 0.
FIN/
/�lfSf�sLt /�i� l®��)� �� AL 01
Contractor Date BY
a
01
I am exempt under Sec.
B.BP.C. for this reason ELI
Plan check fee
a Dat PLUMBING PERMIT ISSUING FEE$ �j o
Signature s
TOTAL FEE o Q •�
Plan check applicant Q,A
�. "
SINGLE FAMILY ��
HOME OWNER-BUILDER DECLARATION Name D?
I hereby affirm that I am exempt from the Contractor's License Address 4 ✓ 'j; t=',_="=
Law for the following reason (Section 7031.5, Business and `
Professions Code): City Tel. No. I; �n.�.
! _its•
1, as owner of the property, will do the work and the '_''}i_ L5 . 0
structure is not intended or offered for sale (Section
7044, Business and Professions Code). i" ;jl- Ja'si d
CONSTRUCTION LENDING AGENCY -
i t'"Nut ,III_!
the
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
abov entioned roperty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permede Date