HomeMy Public PortalAbout5114 DOREEN AVE_Plumbing__ •WORKER'S COMfEN,SAaO{d of consDECLARATION �� .2o obz6 DPW 9/89 APPLICATION FOR PLUMBING PERMIT IJ
'. ! 76A667A
I hereby affirm Thal I have a certificate of consent to self insure,
or a cOrtificale 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.
Policy No. Company
❑ Certified copy is hereby furnished.
F-1Certified
APPLICANTTO FILL IN(PRINT OR TYPE) ADDRESS -�( /`1-• /BUILDING �r /A �la���
Certifietl copy is filed with the county building inspection / N C.
.department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY T�/H / C`
Date Applicant WATER CLOSET NEAREST (i,M /' (fl-7y
•CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. )E / ? �2
COMPENSATION INSURANCE ASSESSOR �,02 PAG�yJ PARCEL ' J
(This section need not be completed If the work involved by the SHOWER MAP BOOK J
permit is for one hundred dollars($100)or less.) OWNER S(GV�
I certify that in the performance.of the work for which this permit LAVATORY
is issued, I shall not employ any person in any manner so as toSINK MAIL 7�/'p C'
become subject to the Workers' Compensation Laws. ADDRESS `Yf OO J1
DISWASHER CITY11-I ��� TEL.NO(�IOJJ 7�
r' /
VDate - LI ApIf / n %`f'� CLOTHESWASHEq VVV CONTRACTOR
NOTICE TO APPLICANT: I after making this Certificate of
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS
provisions or this permit shall be deemed,revoked. AWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO.
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER d
(commencing with Section 7000) of Division 3 of the Business and STAT LI O
SE NO.
Professions Code, and my license is in full farce and effect. GAS SYSTEM OUTLETS ASS U
OUTLETS OVER DIST ICT/N�O.�/ OCE SED [[
5 PER SYSTEM , V X
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License Number Lic.Class FINAL)�� LIDATION.DAT F-W
tl
Contractor Date - Z
❑
am exempt under Sec. FINA ?
BY
B.&P.C.for this reason
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$
Signature
❑ TOTAL FEE
Plan check applicant
SINGLE FAMILY // y
HOME OWNER-BUILDER DECLARATION Name ST�ar /'�/(� - H%-,i T
I hereby affirm that I am exempt from the Contractor's License Law _
�ffoorrr the following reason (Section 7031.5, Business and Professions Atltlress 7¢8" S. �g� zrGD 4v-r, 3307 6.U,_d�-t
t a) p p
City114cA c r ug Tel.Nc�e .j,r _02 ,5"
I,as owner of the property, will do the work and the structure TOTAL
65 - 50
C a��tt
is not intended or offered for sale (Section 7044, Business CI IlhiL LPc o cL1
and Professions Code). - CHECK C:
CONSTRUCTION LENDING AGENCY ��
I hereby affirm that there is a construction lending agency for the CHANCE
performance of the work for which this permit is issued (Sec. 3097,
Civ.C.)
I JiJQQ-S10 8/ IJ
AN ._/'
Lender's Name 27211D1 A 1 S,%1:
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
representatives of this County to enter upon the above-mentioned
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE