HomeMy Public PortalAbout4927 CLOVERLY AVE_Plumbing__ • WORKER'S COMPENSATION DECLARATION 6DPW9/89 APPLICATION FOR PLUMBING PERMIT
" 76A66
I hf;�Zby'affirm that I have a'certificate of consent to self insure, 76A667A
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec. 3800 Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
�
�l'cy NCompany 5�-�j�fS •
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS ��(J
Certified copy is filed with the county building inspection
department. C�,� NUMBER FIXTURE OR ITEM @ FEE
C i LOCALITY C
Date r/ Applicant �lu WATER CLOSET
NEARESTT.
BATH TUB � - A �
CERTIFICATE OF EXEMPTION FROM WORKERS' � CROSS S ,
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the l SHOWER MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) OWNER
I certify that in the performance of the work for which this permit LAVATORY
is issued, I shall not employ any person in any manner so as to SINK MAIL
ADDRESS
become subject to the Workers' Compensation Laws.
DISWASHER CITY TEL.NO.
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM J
LICENSED CONTRACTORS DECLARATION CITYSO � TEL.NO.
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER A
(commencing with Section 7000) of Division 3 of the Business and STATELIC.
Professions Code,and my license is in full force and effect.
GAS SYSTEM OUTLETS LICENSE NO. q-5-1?3 CLASS "^ 3�l V
OUTLETS OVER DISTRICT NO. CJ��PR�OCESSED BY O
/� z 2 3 5 PER SYSTEM �d� CC/lid�
License Number A-5--1 9 / 7 Lia Class C 1G' I/ U
FINAL ,� VALIDATION a
Contractor�� D) 1 �Date 1��— DATE 1
❑ I am exempt under Sec. BY AL '(
BAP.C.for this reason '� /'/'
Date:
Plan check fee pop-
Signature
Signature
PLUMBING PERMIT ISSUING FEE$
❑ TOTAL FEE
Plan check applicant
SINGLE FAMILY mL.J=" s
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law rr• 'j
for the following reason (Section 7031.5, Business and Professions Address
Code):
City Tel. No. -• •• ° -
❑ I,as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). , _ _,_t:
I ?.+
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the C
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 state that the above ,
information is correct. I agree to comply with all County ordinances
and State laws regulating Plumbing, and hereby authorize
representativ s of this C ty to enter upon the above-mentioned
proper t or' spec don urp ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
ature of Ittee Date