HomeMy Public PortalAbout6042ALESSANDRO AVE_Plumbing (3) WORKERS COMPENSATION DECLARATION APPLICATION FOR PLYMRING 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
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING oe
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Certified copy is filed with the county building inspec ADDRESS
tion department NUMBER FIXTURE OR ITEM @ FEE LOCALITY G S�
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST 6gMG LD
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars (;100)or less) LAVATORY MAIL C 5
ADDRESS y�
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner e z CITY i S TEL NOep
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so as to become subject to the Workers Compensation Laws DISHWASHER ~ L'C_ d
CONTRACTOR
Date Apphcan CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making t is Certificate
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth CITY TEL NO
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM
STATE LIC
deemed revoked Z WATER HEATER LICENSE NCLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO P OCESSED Y
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 I 7 v >"
and Professions Code and my license is in full force and effect 5 PER SYSTEM 0
FINAL VALIDATION O
License Number Lic Class DATEl'7 ��P���
99
FINAL O
Contractor Date BY li—
V
I am exempt under Sec LU
N
B&P C for this reason Plan check fee F ►
Date PLUMBING PERMIT ISSUING FEE$ p
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY 0'6 5 7, A
HOME OWNER BUILDER DECLARATION Name z2allllo oe
I hereby affirm that I am exempt from the Contractors License #�o 0 0 0 05
Law for the following reason (Section 7031 5 Business and Address
� � [+
Professions 6,°50
essions Code) City � Tel No Z � r 4
I as owner of the property will do the work and the oda FO 4 6 5 0 w
structure is not intended or offered for sale (Section , 04,20-84 0_ 4
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 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 properLv for i pection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
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ignature of erm ee Date