HomeMy Public PortalAbout6029ALESSANDRO AVE_Plumbing WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
insure or a certificate of Workers Compensation Insurance CE 817(REV 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 FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS as 9 v� �S.Sr4�f O
Certified copy is filed with the county building mspec
tion department NUMBER FIXTURE OR ITEM r@ FEE
LOCALITY � ,�
WATER CLOSET
Dare Applicant NEAREST 1 ,�n�
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST L
COMPENSATION INSURANCE SHOWER OWNER An
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100)or less ) if LAVATORY MAIL
/ 1 C„
I certify that in the performance of the work for which this ADDRESS
permit is issued I shall not employ any person�s�,tcin any mann SINK CITY ' rn 6YZ— TEL N�;R;J_
so as to b ome blect to the W ers ComiIL, s DISHWASHER
CONTRACTOR o ,j
Date "' Applican CLOTHES WASHER ADDRESS S- �'r ��►�5�—
NOTI TO PLIC NT If after make his Certifi
Exemption you should become subject to the WsSWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you muCITY !JAA_,n TEL
T
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATE '/ LIC
deemed revoked WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS " Xa—
and
commencin with Section 7000 of Division 3 of the Business( 9 ) OUTLETS OVER Professions Code and my license is in full forceandeffect 5 PER SYSTEM DATE /� VALIDATION 0
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Lice se Number Lic Class_ �` V
FINAL t)
Contractor t trate (, 0
❑ I am exempt under SecCL
/ W
B&P C for this reason /`��,b G, IU7(ol N
Date
Plan check fee ► Z
PLUMBING PERMIT ISSUING FEE$ l
Signature
TOTAL FEE �0
SINGLE FAMILY Plan check applicant
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s License d 0 7 9 6 A
Law for the following reason (Section 7031 5 Business and Address
Professions Code) City + Tel No o I a o o o`
❑ 1 as owner of the property will do the work and the ? 0034L50
structureis not intended or offered for sale (Section 0 n
7044 Business and Professions Code) , 0 0 0
i
CONSTRUCTION LENDING AGENCY Q 27I 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
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 jaws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
ab v 9mentioneslpr petty for in ection purposes
r SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatu of r ittee Date