HomeMy Public PortalAbout5438 BALDWIN AVE_Plumbing__ WORKERCOMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I he by affirm that I have a certificate of consent to seV 20 0076 DPW 6/$7
in sur.
or a certificate of Workers Compensation Insurance 76A661A
or a ff'ertified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Polio No Company
❑ Certified copy is hereby furnished
r_1 Certified
APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec ADDRESS
tion department NUMBER FIXTURE OR ITEM @ FEE
7 LOCALITY
Date Applicant ✓ WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUBCROSS ST
COMPENSATION INSURANCE V4 OWNER
(This section need not be completed If the work involved by SHOWER
the permit is for one hundred dollars($100)or less ) 3 LAVATORY MAIL
ADDRESS
I certify that in the performance of the work for which this __4�_
permit is issued I shall not employ any person in any manner SINK CITY TEL NO
so as to become subject to the Workers Compensation Laws DISHWASHER I
CONTRACTOR p,7.yci
Date pylic CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If of er making thisrtificate of >/'i/ /V i I%e
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR ,457
Compensation provisions of the Labor Code you must forth CITY
LAWN SPRINKLER SYSTEM H TEL NO
with comply with such provisions or this permit shall be STATE LIC /
deemed revoked / WATER HEATER LICENSE NO / CLASS 3�
LICENSED CONTRACTORS DECLARATION D STRICT NO PROC SSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM 3 OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER YZIA
and Professions Code and m license is in full force and effect 5 PER SYSTEM
Y FINAL VALIDATION a:
License Number 51 a / Lic Class C-36 DATE 0
G
U
/1 FINAL
Contractor 1) koro�SO'lle `j�—v�3�� BY
7 O
❑ I am exempt under Sec W
B 8P C for this reason Plan check fee z
Date PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant r
HOME OWNER BUILDER DECLARATION Name ACtT.g
I hereby affirm that I am exempt from the Contractor s License ''� -� 99.CID
Law for the following reason (Section 7031 5 Business and Address 330
Professions Code) City Tel No 1 ITEM":
❑ I as owner of the property will do the work and the It11A� �- o��
structure is not intended or offered for sale (Section ►
7044 Business and Professions Code) c-
CHEC Y. 95._�.I
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CHANGE •eo
the performance of the work for which this permit is issued
(Sec 3097 Civ C )
Lender s Name COM-0001 j23/90
Lender s Address Aid 9a.2ci
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
ppSEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of �errnotee��ofDate
1