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HomeMy Public PortalAbout5823ALESSANDRO AVE_Plumbing (2) WORKERS'COMPENSATION DECLARATION _l '/ U I hereby, affirm that I have a certifiaote•of consent to self in- 20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT 76A667A sure,or o'terfificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) certified copy thereof (Sec. 3800, Lab: C.) Q. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No.!SA%FnZ Company . Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM @ F E ©�+ / LOCALITY Date . q r� Applicant '�a /. WATER CLOSET(TOILET) �^ NEAREST / CERTIFICATE OF EXEMPTION FROM WORKERS' ! BATH TUB e— CROSS ST. COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by MAIL the perrriit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK mit is issued, I shall not employ any person in any manner so CITYy TEL. N as to become subject to the Workers' Compensation Laws: DISHWASHER CONTRACTOR Q Date Applicant CLOTHES WASHER �S NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS SWIMMING POOL RECEPTOR emption, you should become subject to the Workers'Compen- CITY \, TEL. NO. i1\ sation provisions.b'f the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC. Ss ed WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. ESSED BY I hereby affirm that.l am licensed under provisions of Chapter GAS SYSTEM OUTLETS ri e 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER fed Professions Code, and my license is in full force and ef- 5 PER'SYSTEM. FINAL VALIDATION ��''_``w c ^� DATE License Number .S �'��'1Z Lic. Class jS U S V4lrikk Date FINAL Contractor ��ga• � BY O I am exempt under Sec. f� B.&P.C. for this reason pop.Plan check fee Date: PLUMBING PERMIT ISSUING FEE $ JCU Signature TOTAL FEE SINGLE FAMILY - HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and ACCT Professions Code): Address Cit Tel. No. .°tom 28.50 I, as owner of the property, will do the work and the Y structure is not intended or offered for sale(Section 7044, 1 ITEMS Business and Professions Code): TOTAL_ 5 CONSTRUCTION LENDING AGENCY CHECK 2do0 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (`�{� I (Sec. 3097, Civ. C.). f Lender's Name I130O —L 1 SI29/89 Lender's Address 5362 1 AMCiM 8:"; 1 certify that I have read this application and state that the lt above information' t. I agree to comply with all County ► ordinanc State laws re luting Plumbing, and hereby out ze representative s County to enter upon the ove-mentioned for urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE t5Signature of Perm; a Date