HomeMy Public PortalAbout5303 BALDWIN AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION 20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT
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kyt�rjzby, affirm that I have a certificate of consent to self in- 76A667A 'lUl
sLr, or a'ceitificote of Workers'Compenso4ion Insurance,ora CE 817(REV. 8/86)
v dertiffeGpy thereof.(Sec. 3800, Lab. C.
41
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby.furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING O
Certified copy is filed with the county building inspection ADDRESS ,0-jAf
department. - NUMBER FIXTURE OR ITEM @ FEE LOCALITY _
WATER"CLOSET(TOILET) rG
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB �1 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 ($100)or less.) - LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK
mit is issued,I shall not employ any person_i' any manner so CITY TEL NO.
as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR e r//
emption,you should become subject to rhe Workers'Compen- CITY -?LTEL NO.
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. OCES ED
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS '
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
fed"Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL DATE VALIDATION
i O
License Number Lic. Class U
�/ FINAL 0
Contractor / 1 Y h�Date BY O
I am exempt under Sec. LU
B.&P.C. for this reason
Plan check fee ► g
Date: PLUMBING PERMIT ISSUING FEE$
Signature
• TAIL FEE
TO
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION � _ •
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section'7031.5, Business and 3 `"' a .
.Professions Code): Address
I, as,owner of the property, wCity Tel.do' work and the CTel. No. stili 34a0
structure is not intended or offered for sale(Section 7044, 1 ITEMS
Business and Professions Code).
OTAL 34 -50
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CHECK- 34.50
the performance of the work for which this permit is issued_ CHANGE [I�1
(Sec. 3097, Civ. C.).
Lender's Name
• - C3i�Gl�-1111301 10i 6/89
Lender's Addressv
1 certify that I have read this application and state that the ' GOv
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- ntione roper i sp ct' n purpose .
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Si re ermitte Date