HomeMy Public PortalAbout5802, 5808-10ALESSANDRO AVE_Plumbing t 1 11
WORKERS COMPENSATION DECLARAT16N -� , APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate o? ons4to self 7646771,
insure or a certificate of Workers Compensation Insurance CE 817(REB 10/81)
or a ijttSd4eT7tgy_f 6y 3800 Lab C ) 63`
COUNTY OF LOS ANGELES BUILDING ANAFETY
Policy No Company Ke Tlper Group
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING r i
®` Certified copy is filed with the county building inspec ADDRESS 580 lesaandro Ave
tion department NUMBER FIXTURE OR ITEM @ FEE LOCALITY Temple City
Date 1012/84 Applicant Wilpac Plumb Ing 2 WATER CLOSET 6 121 00 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS Inc BATH TUB 6 12 0 CROSS ST ,Workman Ave
COMPENSATION INSURANCE SHOWER OWNER Fred Wertstein
(This section need not be completed if the work involved by
the permit is for one hundred dollars (;100)or less ) 2 LAVATORY 6 12 00 ADMADIL
RESS 5802 Alessandro
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 6 12 '00
CITY Temple Ctlty TEL NO
so as to become subject to the Workers Compensation Laws DISHWASHER
pA,r��( $6 12 00 CONTRACTOR W
Date Applicant dltdk CLOTHES WASHER �� )00 ADDRESS
NOTICE TO APPLICANT If after making th Certificate of 1422 5 S Ha.11d 1
SWIMMING POOL RECEPTOR
Exemption you should become subject to the Workers CITY TEL NO 770
Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE QQ
$ LIC
deemed revoked WATER HEATER la LICENSE NO 193129 CLASS C- t)
LICENSED CONTRACTORS DECLARATION 6 DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM 3 OUTLETSe $6 1 OQ
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL �J r �
G VALI LION v
DATE �
License Number 193129 Lic Class C-36
®C
Contractor Wilpac Plbg DJpc 10/2/84 BY AL
❑ 1 am exempt under Sec Id.
N
B&P C for this reason ► Of/ Z
Plan check fee S�
Date PLUMBING PERMIT ISSUING FEE$ 10 50
Signature
TOTAL FEE #'¢t®lt�y� 6 81.
Plan check applicant
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Name a
I hereby affirm that I am exempt from the Contractor s License Address t °,1 1 2 51�
Law for the following reason (Section 7031 5 Business and I
Professions Code) City Tel No o ° 1 1 2 5 0
❑ I as owner of the property will do the work and the ' Q O 3 r 8 4
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
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 tioned property for i pection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
10/2/84
Signature of ittee Date r r Qty CAA
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