HomeMy Public PortalAbout5922 BURTON AVE_Plumbing__ VJORKERS COMPENSATION DECLARATION 20-0026 DPW 9/e9 APPLICATION FOR PLUMBING PERMIT
�I hereby affirni'that'l that•I have a certificate of consent to self insure,
or a pertificate of Worker's Compensation Insurance, or a certified
copy th f Sec. 3800 Lab. C.) - -
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS?" DEPT.OF.PUBLIC WORKS DIV.
P❑alicy No. Company - - - S\ •t ...r
Certified copy is here furnished.
❑ FOR.APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with'th ounty building inspection " ADDRES O�
department NUMBER FIXTURE OR ITEM @ FEE LOCALITY EM �•�' /�
Date Applicant WATER CLOSET ,�s a '',S' NEAREST
CERTIFICATE OF EXEMPTION FROM.WORKERS' BATH TUB - `�J q CROSS ST.
COMPENSATION.INSURANCE s;J O oma✓ ASSESSOR - -
(This section need not be'completed if the work involved by the a SHOWER 1 G MAP BOOK PAGE PARCEL
permit is for one hundred dollars($700)or less.) LAVATORY. )` gZ) OWNER N M��
I certify that in the performances of the work for whit this 6 mnt S/
/ ��
is issued, shall not employ any person iAIL
n any so s to IN' �'" _ rL oJ� ADDRESS ' �g
become.subject to the Workers'Compensation L S.
DISWASHER ��� , CITY TE2 e2 gzz
Date I� Apo
licant CLOTHES WASHERN OT - -
CONTRACTOR / r�
Exemp n,y APPLICANT: e r making t is C Niensa of
Exemp ion,you should become du lett to the Wo Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDREB 'j
provisions or this permit shall be deemed revoked. t LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CI _ 26 qQ
• � TEL.NO. }
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER J/'S d
(commencing with Section 7000)of Division 3 of the Business antl TATE (,.- ,/ / LIC. �$ p O
GAS SYSTEM �—OUTLETS LICENSE NO. \I f l(, 'fit CLASS (,�� D9 (�
Professions Code,and my license is in full force.and effect. Y
OUTLETS OVER DISTRICT NO. PROCESSED BY
/(. I�- �/ 5 PER SYSTEM,
License Number / `v Lia Class�1. �L
? ,^f� ^� ^.� FINAL VALIDATION W YvY W40 I -3I��J DATE
DOnI(actor Data
FINAL 7✓ � Z
I am exempt under Sec. _ BY JNWI
UT
8.8P.C.for this reason -Plan check check fee D
.Sign
Date: L/
atu PLUMBING PERMIT ISSUING FEE$ "7 ��, �Q�•cMi i.
❑ TOTAL FEE �' Q p ,�!'%d'n 6 e f
Plan check applicant ' �f: �'(>i
SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name - - LM- -/ C-Q�J Z-. (;�'/!'s•� .i F'
I hereby affirm that I am exempt from the Contractor's License Lawfor the following reason (Section 7031.5, Business and Professions Address - / - /�� 21Z.)
Cade):
❑ - City Tel. No.
I, as owner'of the property,will do the work antl the structure,
is not intended or offered-for sale (Section 7044, Business -f_ts. {. :ice. •�•'',
and Professions Code).
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 slate that the above
information is correct. I agree to comply with all County ordinances
and State laws regulati bing, and hereby authorize
representatives o nt a ter upon the above-mentioned
property for in ion purposes. ^ - SEE REVERSE FOR EXPLANATORY LANGUAGE' '
Signature of Permittee