HomeMy Public PortalAbout5827ALESSANDRO AVE_Plumbing (4) WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT ��77
I'herPby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 G, I
'insure, or a certificate of Workers' Compensation Insurance, 76A667A lul
or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES 'DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished.
El Certified
APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 582 7 ALESSAAI DR0 AVS,
Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date Applicant 2 WATER CLOSET �Q NEAREST '11'
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB a� CROSS ST. S/ �S 7NAJ�
COMPENSATION INSURANCE SHOWER OWNER AAJ*
(This section need not be completed If the work involved by MAIL
the permit Is for one hundred dollars (:100)or less.) LAVATORY a f ADDRESS �/ LAS
I certify that in the performance the work for which this �E'M (E G Z
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 d ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL. NO.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. ` WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION r DISTRICT NO. CPROCESSED
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS cJ0
(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 VALIDATION 0-1
DATE
License Number Lic. Class Q.
FINAL
Contractor Date BY
❑ I am exempt under Sec.
B.&P.C, for this reason Plan check fee
Z
Date: PLUMBING PERMIT ISSUING FEE$ 3
Signature
TOTAL FEE Or
Plan check applicant
SINGLE FAMILY 3
HOME OWNER-BUILDER DECLARATION Name Accl•st
I hereby affirm that I am exempt from the Contractor's License '
Law for the following reason (Section 7031.5, Business and Address
Professions Code): City Tel. No.
t _
I, as owner of the property, will do the work and the _
structure is not intended or offered for sale Section ® t`a i, L ="'•k
7044, Business and Professions Code). _
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for {HAIN of li:;
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name . .:•.)•� ;=?I,€�. w+l.,:..... _
Lender's Address `�_} v? a ? �k'•d
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-m ned roper for inspection purposes.
/ SEE REVERSE FOR EXPLANATORY LANGUAGE
elute o rmit a Date