HomeMy Public PortalAbout6033ALESSANDRO AVE_Plumbing (2) ION
WORKER'S I have
a certificate
of consent to 76A626DPW9/89 APPLICATION FOR PLUMBING PERMIT
76A667A
I hereby: that I have a certificate of consent to self insure,
or a certifictem of Worker's Compensation Insurance, or a certified
copy therenf(Sec. 3800 Lab.C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
Policy No. Company
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS❑ 6ba� 1\L
Certified copy is filed with the county building inspection
department. NUMBER FIXTURE OR ITEM
@ FEE LOCALITY '
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the SHOWER MAP BOOK t PAGE PARCEL
J
permit is for one hundred dollars($100)or less.) LAVATORY OWNER o1 vp, �y` �
I certify that in the performance of the work for which this permit iP+U
is issued, I shall not employ any person in any manner so as to MAIL
SINK ADDRESS tovJ (��551�xi�4
become subject to the Workers'Compensation Laws.
DISWASHER CITY /°j-TtiJ TEL.NO.
Date Applicant CLOTHES WASHER v I O
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR F0 Sew6L�_
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS 6 Ae�� ruT
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY&�� �G� ��2t� TEL.NO. -L7-7yU }
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER (jV t��}ice. a0
(commencing with Section 7000)of Division 3 of the Business and STATE �y LIC. ` y O
Professions Code, and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. 3 Dd S 7 CLASS (, J& 0
OUTLETS OVER DISTRICT NO. PROCESSED BY a:
5 PER SYSTEM Q
License Number Lic.Class
FINAL V
DATE 3_.23 VALIDATION W
Contractor Date a-
❑ I FINAL !it.t:', Z
am exempt under Sec. BY
B.&P.C.for this reason _-i_=-`' +°,{r!'•
Plan check fee i i T Z IliC`
Date:
Signature
PLUMBING PERMIT ISSUING FEE$ <
•t
❑ TOTAL FEE
.3 SE"viv
Plan check applicant ?
SINGLE FAMILYt.t;;-�Q �}�}_}
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions Address
Code):
❑ City Tel. No. _ �. •
I, as owner of the property,will do the work and the structure !s4 4 6 f f:;
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 the
performance of the work for which this permit is issued (Sec. 3097,
Civ.C.)
Lender's Name
Lender's Address
I certify at I have read this application and state that the above ,
infor ion i correct. I agree to comply with all County ordinances
and ate la s regulating Plumbing, and hereby authorize
repre atlVeS of this County to enter upon the above-mentioned
prope r ins action purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
3 - jIl 95
Signa ur f Pe mittee Date