HomeMy Public PortalAbout5937ALESSANDRO AVE_Plumbing WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I her b affirm That I have a certificate of consent to self in-
y� 20-0026 DPW 4/90 76A667A
sure,or a ce�::ficate of Workers'Compensation Insurance,or a n
certified co thereof (Se . 3800, Lab. C.) ,ILJII
_EZL� .p COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No.i3i�l'iP.1� Company _%lyu
Certified copy is hereby furnished..
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE
}, � LOCALITY C�
Date S' -t-55 Applicant X-.)ir Y'eh J_a WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST. ty�Ly
COMPENSATION INSURANCE SHOWER OWNER S,(_X QAX
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) ` LAVATORY ADDRESS , etac�p
I certify that in the performance of the work for which this per-
SINK CITY TEL. NO.
mit is issued, I shall not employ any person in any manner so
as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR C ^
Date Applicant CLOTHES WASHER ADDRESS C vql,,11,Y
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption,you should become subject to the Workers'Compen- CITY'-- TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS ° l
ly with such provisions or this permit shall be deemed revok- STATE I LIC. ,
ed. WATER HEATER LICENSE NO. qO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
l
fect. //� //p},//;.� p HOSE BIB DATE
License Number -O`C"1 3 1 Lic. Class 11= I=y`"= CL
° FINAL �s i-= O
Contractor +�`�&114f. C,Date "(� BY L -°t- _ U
I am exempt under Sec. l rAL 74 = 1 UP A
B.&P.C. for this reason Plan check fee ► wL ° iaft LU
Date: �.:(i( Ls� _U (!1
PLUMBING PERMIT ISSUING FEE$ Z�
Signature
TOTAL FEE
SINGLE FAMILY 1_}l0L)0 (=i i-_ 5/17/95
HOME OWNER-BUILDER DECLARATION Plan check applicant c i rt: Ar F5r.
I hereby affirm that I am exempt from the Contractor's License Name
Low for the following reason (Section 7031.5, Business and
Professions Code): Address
OO eh .r.. �
Fj I, as owner of the property, will do the work and the City Tel. No.Wo
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 t
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
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes.
S'(7_9 SEE REVERSE FOR EXPLANATORY LANGUAGE
ture of Permittee Date