HomeMy Public PortalAbout4940 DOREEN AVE_Plumbing__ 20-0026
WORKER'Shave a certificate of
76A667A PW 9189 APPLICATION FOR PLUMBING PERMIT LI
I herebyaffirm that I have a certificate of consent to self insure, ,
or a certificate of Worker's Compensation Insurance, or a certified -
�copy4htreot(Sec.3800 Lab.C.) - - - --- - _
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT- OF PUBLIC WORKS DIV.
Policy No.58D1D'47 Company Gate—L'y1T1C1 c - , ,
Poli
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
department..
m copy is filed withthec nt buildi in tion
. ., epadmept.. NUMBER FIXTURE OR ITEM @ FEE LOCALITY - '-
Me le it
Dale F-11—QT Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. pr-
COMPENSATION INSURANCE. ASSESSOR
(This section need.not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL
Permit is for one hundred dollars($100)or less.) LAVATORY OWNER Ted Sirene
I certify that in the performance of the work for which this permit
is issued, Ir shall not employ any person in any manner so as to SINK MAIL
become subject to the Workers' Compensation Laws, ADDRESS 4940
' DISWASHER CITY 1e Uty TEL.NO.448-4476
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of NTRACTOR
Exemption,you should becomesubject to the Workers' Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS
provisions or this permitshelfbe deemed revoked. LAWN SPRINKLER SYSTEM - p
LICENSED CONTRACTORS DECLARATION CITY TEL.NO.�d �/2/ T
I hereby affirm that I am licensed under provisions of Chapter 9 WATER 4.
(commencing with Section 7000) of Division 3 of.the Business and STATE q Q(7 G LIC. O 0
P GAS SYSTEM OUTLETS LICENSE NO. Y CLASS U
Professions Code,and my license is in full,force and effect.
OUTLETS OVER DISTRICT NO. Q PROCESSED BY
��a .�Q�
OPER SYSTEM Q
Crr
License N r 274880 Lic.Class C-20
FINAL P �7/ VALIDATION W
6-11-91 . DATE / 0 a
Contra tar ate to
❑ I am exempt under Sec.• FINAL - Z
B.BP.C.for this reason
Plan check fee
Date:
Signature
,PLUMBING PERMIT ISSUING FEE$ B.Q
I
❑ TOTAL FEE
Plan check applicant -
SINGLE FAMILY - 17.l.T n
HOME OWNER-BUILDER DECLARATION Name - t- ' •T '
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions Address 'Al it t• i
Code):
City Tel. No.
❑ -1, 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).
CONSTRUCTION LENDING AGENCY t-..-C
I hereby affirm that there is a construction lending agency for the - - 4tl;lPit]
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 D'
and State laws regulating Plumbing, and hereby authorize
representatives of this County to enter upon the above-mentioned
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE '