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HomeMy Public PortalAbout6056ALESSANDRO AVE_Plumbing (2) WORKERS'COMPENSATION DECLARATION20-0026 APPLICATION FOR PLUMBING PERMIT �1 MI herehy, affirm that I have a certificate of consent to self in- 76A667A PW 4/87 r sure,or a certificate of Workers'Compensation Insurance,ora CE 817(REV. 8/66) 'tUl certified copy thereof (Sec. 3800, Lab. C. . COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE)" 7BDG /O // / S S /V Certified copy is filed with the county build i nspectio S (j �'J/ NUMBER FIXTURE OR ITEM FEE Y department. / @ Date A)-3 —IR7 Applicant JWATER CLOSET(TOILET) T pp CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB ST. Adc COMPENSATION INSURANCE SHOWER OWNER A (-k "F(,e ` (This section need not be completed if the work involved by MAIL 9 the permit is for one hundred dollars ($100) or less:) LAVATORY ADDRESS �Q �e�S��y d_ I certify that in the performance of the work.forwhich this per- mit is issued, I shall not employ any person in any manner so SINK CITY �� /� C't� TEL. NO. as to become subject to the Workers' Compensation Laws. DISHWASHER p,p CONTRACTOR GeQ2 e v&eA Z/� Date Applicant CLOTHES WASHER ADDRESS 30 2 /✓, 14,--Sell` A NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR y emption,you should become subject to the Workers'Compen- CITYr tj AA)A TEL. NO. sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM w ly with such provisions-or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. T 3d f� C- CLASS LICENSED CONTRACTORS DECLARATIONGAS SYSTEM OUTLETS `j f'jyUf(( TRICT�Y PROCESSJD e I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER r and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL V LI ATION fect. // _2 DATE V O L c // y-3 ense Number Y. ©6� Lic. Class J S ` U FINAL Contractor'W-©9 Z1- Date 10-8-99 BY O ElI am exempt under Sec. Lydd !� B.BP.C. for this reason Plan check fee , U) Date:.- PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that l am exempt from the Contractor's License Name ='''f ? Law for the following reason (Section 7031.5, Business and ITEMS Professions Code): Address 1 G I; as owner of the property, will do the work and the City Tel. No. TCIIHL t6.+ 50 structure is not intended or offered for sale(Section 7044, ( Business and Professions Code). � _ CONSTRUCTION LENDING AGENCY CHANkiE 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 laws regulating Plumbing, and hereby authorize representatives of this Co ty to enter upon the above-menti ned opert for ' sp on 'purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE -:111S17g_r�a_tu_re of Permittee Date