HomeMy Public PortalAbout5520 PARMERTON AVE_Plumbing_3/14/1990_sink, dishwasher WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have o certificate of consent to self 200026 DPW 6/87 G I
insure or a certificate of Workers Compensation Insurance, 76AG67A lul
or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Pal icy No ID- Company SATE )CV'UD
Certified copy is hereby furnished
® FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDINGA
Certified copy is filed with the county building mspec ADDRESS Za CPMAI -
lion department NUMBER FIXTURE OR ITEM ® FEE
1i _1 i LOCALITY � p� G 44, q $b
Date 3�/3 90 Applicant "��0 IE��N� WATER CLOSET NEAREST �1
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST SV{ILli AWIr,4 $F P41WCS
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work Involved by r
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the permlt Is for one hundred dollars ($100)or less ) LAVATORY ADDRESS 55Z0 rARM &04001 AO
I certify that in the performance of the work for which this
permit is Issued I shall not employ any person in any manner Z SINK CITY T G /uL -� O TEL NO
11 I
so as to become subject to the Worker Compensation Laws DISHWASHER C;4r
c CONTRACTOR JE Ga ER4y NI
Dote3 /./3�7� Applicant �S�/ CLOTHES WASHER
NOTICE TO APPLICANT If after making this Certificate of ADDRESS 5 Z FFA!•tll.T'OM RUE 3 4
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR /I
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY Gar ZC. 6 TEL N 6-31-6114
with comply with such provisions or this permit sholl be STATE LIC
deemed revoked WATER HEATER ILICENSE NO 5Zo CLASS
LICENSED CONTRACTORS DECLARATION DIS ESSE Y
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER }
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINA VJI1L16AT 61N Ll;
DATE O
License Number /SZoBf Lm Class U
FINAL �
Contractor��Date 33 3�G BY Ir
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❑ ~
I am exempt under Sec (�
W
B 8P C for this reason Plan check fee , V)
Date Z
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY ACCT_4
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s LicenseAddress =�u7 ?"00
Law for the following reason (Section 7031 5 Business and
Professions Code) City Tel No i ITEMS
❑ 1, as owner of the property will do the work and the TOTAL 27$ - Qp
structure is not intended or offered for sale (Section
7044 Business and Professions Code) CRECY 23.00
CONSTRUCTION LENDING AGENCY LHAW3E .00
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec 3097 Gv C )
0000-MOI 3/14/90
Lender s Name
9503 1 AM 9:09
Lender s Address
I certify that I have read this application and slate 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 en ro rty for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
3/3-%a
ignature of P ittee Date