HomeMy Public PortalAbout5833ALESSANDRO AVE_Plumbing WORKERS' COMPENSATION DECLARATION20-0026 } APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consent to self in- 76A 6 ADPW 4/87
sure,or a-certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86)
certified ppy thereof (Sec. 3800, Lab. C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING $
❑ Certified copy is filed with the county building inspection ADDRESS �V�� - s5oletm hve. 7 C
department. NUMBER FIXTURE OR ITEM Q FEE
LOCALITY
' WATER CLOSET(TOILET)
Date Applicant NEAREST
BATH TUB. CROSS ST. Cc i L[i7k S
CERTIFICATE OF EXEMPTION FROM WORKERS' �O
COMPENSATION INSURANCE / SHOWER A OWNER. flQhch f-1a`
(This section need not be completed if the work involved by V MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS �, Q 1,wk
1 certify that in the performance of the work for which this'per- SINK �+
mit is issued, I shall not employ any person in any manner so CITY t TEL. N(O�� r
as to become subject to the Workers' Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS
emption, you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR
CITY TEL. NO.
sation provisions of the Labor Code,,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS (�
9'(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my.license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
fect. DATE
License Number Lic. Class O
U
FINAL
Contractor Date BY O
El I am exempt under Sec. U
!bJ
B.&P.C. for this reason , U)
Plan check fee �
Date: PLUMBING PERMIT ISSUING FEE$ �O
Signature
TOTAL FEE
SINGLE FAMILY
HOME OWNER-BU ILDER.DECLARATION Plan check applicant
I hereby affirm that,l am exempt from the Contractor's License Name
Law f r the following reason (Section 7031.5, Business and
Prof ssions Code): i TT 3
Address ,i
1, as owner of the property, will do'the"work-and the City Tel. No. = 00
structure
F °r -
structure is not intended or offered for sale(Section 7044,
Business and Professions Code)_ �+-�"• -° =-
CONSTRUCTION LENDING AGENCY ► ='HA'
I hereby affirm that there is a construction Tending agency for
the performance of the work for which.this permit is issued
Sec. 3097, Civ. C. Ui
Lender's Namer fi'; ?a '•
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 t the
ab ve-mentio erty or ins ection pu oses., �.
SEE REVERSE FOR EXPLANATORY LANGUAGE Sho �Y
Signature of.Perm Date S+�+lf( 2