HomeMy Public PortalAbout5823ALESSANDRO AVE_Plumbing (3) WORKER'S COMPENSATION DECLARATION DPW 9/89 APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I fi8ve a certificate of consent to self insure, 76A667 76A667A
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec 380 ab.C.) 6k
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
Po Company
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county uil ng i s e ion ADDRESS
departmen NUMBER FIXTURE OR ITEM Q FEE LOCALITY
Date Ap WATER CLOSET NEAREST
CROSS ST.
CERTIFICATE OF 5pleted
P ON FROM WORKERS' BATH TUB
COMPEI INSURANCE ASSESSOR
(This section need not be if the work involved by the SHOWER MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) OWNER
LAVATORY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as toMAIL
SINK ADDRESS
become subject to the Workers'Compensation Laws.
DISWASHER CITY EL NO2
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of CONT_ I
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS // 1 r
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM (((///���//�
LICENSED CONTRACTORS DECLARATION CITY TEL;Nb
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER 0
STATE LIC.~i'•e
(commencing with Section 7000) of Division 3 of the Business and LICENSE NO. CL•A99t' F"�`;
Professions Code,and my license is in full force and effect. GAS SYSTEM / OUTLETS /
DISTRICT NO. PROCESSED BY• li.;;,
OUTLETS OVER .-
J —3q
5 PER SYSTEM
License Number Lic.Class
DATE f2�Z� VA4iIUATIONFINAL
�~-d °IL
co
FINAL _z
I a exempt under Sec. BY
B.&P.C.for this reason
Plan check fee
Date:
Signature PLUMBING PERMIT ISSUING FEE$ Gj v -_ `'._J
❑ TOTAL FEE I, 0 i.
SINGLE FAMILY Plan check applicant
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 Professions Address
Code):
City Tel. No.
F-1 \
I,as owner of the property,will do the work and the 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
I
Lender's Address
1 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 law regulating Plumbing, and hereby autho ize
represent ti of t sCo .ty to ente upon the abov -menti ned
spec on pu SEE REVERSE FOR EXPLANATORY LANGUAGE
r - fay
ignature of Permitt a Date