HomeMy Public PortalAbout6056ALESSANDRO AVE_Plumbing (3) 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.S��� Eompanyy�� `�'L�� r
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date����o��4ppli4ant �\�Z�� � WATER CLOSET NEARESTST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB �� CROSS {�„Z
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS ,
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO. ,0,,_R R
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS `
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS QN—
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS f 10 �1 C:
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL /� � VALIDATION
—` TE ! ">
License Number-���R CSN Lic. Class_�s�
1 FINAL
Contractor �� �nCAC Vf Date ` �—� BY q FzJJ
as
❑ I am exempt under Sec.
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B.BP.C. for this reason
Plan check fee
Date:
Signature
PLUMBING PERMIT ISSUING FEE$
J
TOTAL FEE 5
s ' o
SINGLE FAMILY
Plan check applicant ✓ c ° 2. 5 0
'
HOME OWNER-BUILDER DECLARATION Name2.J O c
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address e� �� f L, 1 J`— P
Professions Code): City Tel.
❑ 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). Poo
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 laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes.
\A �y SEE REVERSE FOR EXPLANATORY LANGUAGE
`�\ _4� i2—
Signature of Permittee Date