HomeMy Public PortalAbout6009ALESSANDRO AVE_Plumbing WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
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I hereby affirm that I have a certificate of consent to self 76A667A
insure or a certificate of Workers Compenso ion Insurance CE 817(PEV 10/81)
or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
❑ Certified copy is hereby furnished BUILDING )) ff J
F1 Certified
APPLICANT TO FILL IN(PRINT OR TYPE) DDR SS (1L ^3s y �
Certified copy is filed with the county building inspec
tion department NUMBER FIXTURE OR ITEM a FEE LOCALITY
WATER CLOSET '� L
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
COMPENSATION INSURANCE , SHOWER / r OWNER ry-r
(This section need not be completed if the work involved by V MAIL
the permit is for one hundred dollars ($100)or less ) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CITY _ LI TEL NO.20,3
so as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making this Certificate of
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
CITY TEL NO
Compensation provisions of the Labor Code you must forth
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PRO ESSE `BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS !'t /1�
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER �,J (/ }
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL� A.
VALID TION u
+ DATE r
License Number Lic Class OC
FI O
Contractor Date B ;? 1 4 5 8 A u
# 0 0 0 0 0 5
❑ I am exempt under Sec I o o34,50 Z
B 8P C for this reason
Date Plan check fee 00. 0 0 0 7j 4 5 Q
PLUMBING PERMIT ISSUING FEE$ p 1 3 1 _85
Signature '+
TOTAL FEE S f'
Plan check applicant
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Name _
I hereby affirm that I am exempt from the Contractor s License Address
Law for the following reason (Section 7031 5 Business and
W9 N, ALESSAMWN) WE
Professions Code) City T C Tel No4
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) s
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
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 jaws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
above mentioned property for inspection purposes
f SEE REVERSE FOR EXPLANATORY LANGUAGE
Aignc,/ureof- ermitteee Date
D~ - T� b 4 i