HomeMy Public PortalAbout5550 BALDWIN AVE_Plumbing__ WORKERS'CC 1vPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
hereby affirm that_[ hnve a certificate of consent to self 76A667A
sure, or a certiific of Workers'Compensation Insurance, CE 817(REV. 10/81)
r a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
olicy No. Company
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 LOCALITYIII IF o2y
ate Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. vl 0 j' ✓
COMPENSATION INSURANCE OWNER
SHOWER _
his section need not be completed if the work involved by MAIL
e permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESSi°
certify that in the performance of the work for which this
ermit is issued, I shall not employ any person in any manner SINK CITY TEL. NO. a Z 21
as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR /U
ate e�'2 +'4 Applicant� .W12 CLOTHES WASHER ADDRESS
IOTICE TO APPLICANT: If, after making this Certificate of
emption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY TEL. NO.
ompensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
ith comply with such provisions or this permit shall be STATE LIC.
eemed revoked. WATER HEATER LICENSE NO. ASS
LICENSED CONTRACTORS DECLARATION GAS SYSTEM OUTLETS DISTRF NO. XCESSED BY
hereby affirm that I am licensed under provisions of Chapter 9
ommencing with Section 7000) of Division 3 of the Business OUTLETS OVER
nd Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL f f VALIDATION
DATE `
cense Number Lic. Class F�
FINAL
ontractor Date BY 4D
sw
I am exempt under Sec. w
B.&P.C. for this reason 00.Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name A' I 6� 44 � Q CI�' Ahereby affirm that I am exempt from the Contractor's Licenseo'0 0 0 0J
aw for the following reason (Section 7031.5, Business and Address ,,) C V �r
rofessions Code): Cit f7zV�� Ozy, 2 Tel. No. 7 6 U ;o.0 1 6,5 0
I, as owner of the property, will do the work and the r _
structure is not intended or offered for sale (Section 110.
7044, Business and Professions Code). G 4,2 q _8 a
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency for
e performance of the work for which this permit is issued
ec. 3097, Civ. C.).
ender's Name
nder's Address
certify that I have read this application and state that the ,
bove information is correct. I agree to comply with all County
rinances and State laws regulating Plumbing, and hereby
uthorize representatives of this County to enter upon the
Fgnature
ve-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
of Permi tee Date