HomeMy Public PortalAbout5801ALESSANDRO AVE_Plumbing -WORKERS' COMPENSATION DECLARATION APPLICATION ■ ®„ PLUMBING PERMIT
nureby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, Fir a CCTW. tate of Workers' Compensation Insurance, 76A667A
or a certified ,fi(Ffec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT:-O.F'PUBLI-C WORKS "-
Policy No. Company
❑ Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING' (/ /' �
Certified copy is filed with the county building inspec- ADDRESS - %„_!0 C/ �C
tion department. NUMBER FIXTURE OR ITEM @' - FEE /s
/� LOCALITY (��'�
Date Applicant , WATER CLOSET 4! NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB o CROSS ST.- «•
COMPENSATION INSURANCE OWNER, ,[ 124
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars ($100)or less.) LAVATORY the
ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY ' TEL..NO� �..
so as to become subject to the Workers Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS�>q
NOTICE TO APPLICANT: If, after making this Certificate of F
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR ,+�7
Compensation provisions of the Labor Code, you must forth- CITY, V� TEL. NO ,. 7-XI
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATELIC.
deemed revoked. WATER HEATER LICENSE NO + 2'7CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESS BY
GAS SYSTEM OUTLETS f
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full fore nd effect. 5 PER SYSTEM
L \ DATE
FINAL
AEL VA AT60N 0,
License Number Lic. la
,�,J �j �r ss FINAL
.,
Contract fa-!"'u"L! �U .�S BY �
❑ I am exempt under Sec.
B.BP.C. for this reason CQ
Plan check fee v
Date: PLUMBING PERMIT ISSUING FEE$ O Q 0 A
Signature
TOTAL FEE # 0 ° 0 0 0 5
Plan check applicant
SINGLE FAMILY ( ° °3 4, 5,0.
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address ° ® 3 Q,v 0 UX
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the ( 26 -88
structure is not intended or offered for sale (Section 0.
7044, Business and Professions Code). PP
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
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 An
' s of this County to enter upon the
ab ty for inspection purposes.
la--�S f ,ySEE REVERSE FOR EXPLANATORY LANGUAGE
Date '