HomeMy Public PortalAbout5135 FARAGO AVE_Plumbing__ �RKERS' COMPENSATION DECLARATION
s 20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT
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`I'h reby, affirm that I have a certificate of consent to self in 76A667A 'lUl
s4e,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86)
certified.'copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No;r—yZLOLCompany
Certified (fopy is hereby furnished. - BUILDING
FOR APPLICANT TO FILL IN (PRINT OR TYPE) /� 1/I✓� yJ/ v�
Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date l Applicant /!!/la O� WATER.CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' I? BATH TUB ROSS ST.
COMPENSATION INSURANCE SHOWER OWNERJ�GLC S(:
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY DDRESS
I certify that in the performance of the work for which this per- SINK pp
mit is issued, I shall not employ any person in any manner so CITY ��� TEL. �a?�_ 90�
as to become subject to the Workers'Compensation Laws. DISHWASHER p
�� CONTRACTOR ��i11,4 /(0
Date Applicant CLOTHES WASHER �74ADDRESS
a!h
NOTICE TO APPLICANT: If, after making this Certificate of Ex-' SWIMMING POOL RECEPTOR
emption, you should become subject to the Workers'Compen- CITY. �7 - TEL*J Zl 3l /
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM G
ly with such provisions or this permit shall be deemed revok- STATE �{/��) LIC.
ed. /l WATER HEATER (CENSE NO. c �///&/3 CLASS 3�
LICENSED CONTRACTORS DECLARATION DIS Nq,�l� ROCESSED BY
I hereby affirm that I am licensed under provisions of'Chapter GAS SYSTEM OUTLETS (//(1
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
fed Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL j0. VALIDATION
Q a DATE O
License Numb r �/®yl-� Lic. Class�� 0
p�! FINAL
Contractor !vim Date ` BY 00
ElI am exempt under Sec. LU!
IL
B.&P.C. for this reason— Plan check fee
Date: tl PLUMBING PERMIT ISSUING FEE$
Signature TOTAL FEE T P -�
SINGLE FAMILY - -t=.. _fes 'E
y
HOME OWNER-BUILDER DECLARATION Plan check applicant _ -- – –
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and
Professions Code): Address
ElI, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044, f
s
Business and Professions Code). (""t'" "¢ " ` 4
7 V-
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 )wf 101t A//I< Q�
Lender's Address
I certify that I have read this application and state that the oil.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- entioned prop e ty for inspection purposes.
1" Ste_ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permitted Date