HomeMy Public PortalAbout6042ALESSANDRO AVE_Plumbing (2) WORKERS COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT
Winsure
hereby affirm that I have a certificate of consent to self 76A667A
or a certificate of Workers Compensation Insurance CE 817(REV 10/81)
r certif ed co y th r of Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY '-r
Policy No-Company '
Certified copy is hereby furnished `
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
G119Certified copy is filed with the co ty building mspec ADDRESS
tion department NUMBER FIXTURE OR ITEM @ FEE LOCALITY
WATER CLOSET
Date i1� Applicant NEAREST
CERTIFICATE OF EXEMPTION FROWWORKERS BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less ) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner t SINK CIT / TEL NO _,� 3
so as to become subject to the Workers Compensation Laws DISHWASHER h�
CONTRACT R
Date Applicant CLOTHES WASHER ADDRESS
NOTICETO APPLICANT If after making this Certificate of SWIMMING POOL RECEPTOR
Exemption you should become subject to the Workers 7
Compensation provisions of the Labor Code you must forth CITY TEL NO �J
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER LICENSE NO= .,� CLASS Ci3�
LICENSED CONTRACTORS DECLARATION DISTRICT NO PR
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL0
q `/ __� DATE 17 VALI TION u
License Numberr,�/�7 S Lic Classes p�
FINAL O
Cantroctor�seQ�, ., ., Date �a� BY �� ^d'fw��a U
UW
❑ I am exempt under Sec `� h
B 8P C for this reason Tc 10713
13 C fL (j e
Plan check fee ►
Date U r r` a o c o `
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE °to ,G
Plan check applicant 6 a 7 Q v 0
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Name U 0 7_v
I hereby affirm that I am exempt from the Contractor s License Address
Law for the following reason (Section 7031 5 Business and
Professions Code) City Tel No
❑ I as owner of the property will do the work and the
structureis 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 that I have read this application and state that the
above inform n is correct I agree to comply with all County
ordinances nd State laws regulating Plumbing and hereby
authoriz representatives of this County to enter upon the
above entioned pro ty for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of ittee Date