HomeMy Public PortalAbout5802, 5808-10ALESSANDRO AVE_Plumbing (2) WORKERS COMPENSATION DECLARATION teasstA
I hereby affirm that I have a certificate of ca+iserit to pelf cE eir (z 0*- APPLICATION FOR PLUMBING PERMIT {�
insure or a certificate of Workers Compensation Insurance or J
a certified copy thereof(Sec 3800 Lab C)
t COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING �I
O1ZD
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE ADDRESS Oa ALe55A
pie a me t LOCALITY
Date Applicant AL11WLv a4/LdE1lS WATER CLOSET NEAREST
BATH TUB CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE SHOWER OWNER /��BS GuER T1
LAVATORY MAIL
(This section need not be completed if the work involved ADDRESS
by thepermitis for one hundred dollars ($100) or less) SINK CITY Q�! TEL NO IY7^z p
I certify that in the performance of the work for which this DISHWASHER r U
permit is issued I shall not employ any person in any manner CONTRACTOR
so as to become subject to the Workers Compensation Laws CLOTHES WASHERC)
ADDRESS d
Date Applicant SWIMMING POOL RECEPTOR , G �G / U
NOTICE TO APPLICANT If after making this Certificate of CITY I& ave&V' TEL NO b� w
Exemption 'you should become subject to the Workers LAWN SPRINKLER SYSTEM STATE ,� LIC /� to
Compensation provisions of the Labor Code you must forth LICENSE NO LTJ CLASS O— Z
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked GAS SYSTEM OUTLETS DISTRICT NO PROCESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER .
I hereby affirm that I am licensed under provisions of Chapter 15 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi FINAL �—���� VALIDATION
ness and Professions Code and my license is in full force and DATE
effect �^i (j (� /j
License Number 2Ar3 ` Lic Class u�� BY
.t/0 p.� ...
ContractorA�MD 64140W Date 114yIn=
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051 Bus
sm-
iness and Professions Code) TOTAL FEE
Lic or Reg No Date Plan check applicant
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractors Address r
License Law for the following reason (Section 7031 5 Busi City Tel No -9 6 4 G,2 A
ness and Professions Code)
DI as owner of the property am exclusively contracting # o 0 o o o 5
with licensed contractors to construct the project
(Section 7044 Business and Professions Code) ° ° 1 2 5 0
CONSTRUCTION LENDING AGENCY 0 0 0 12506
I hereby affirm that there is a construction lending agency 0924-82
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
above mentionedrniroperty f inspection purposes
2Signq12-
Signature
ature of Permittee Date