HomeMy Public PortalAbout5507 GOLDEN WEST AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION CE76A667
81 e»( ) APPLICATION FOR PLUMBING P E R M I T
" I hereby affirm that I (la CE ave certificate of consent to self 2-80
insure, or a certificaKe of Workers'Compensation Insurance,or
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a certifi d copy they qf,(S c )800,Lab.C.) *�
1R1t ;y D ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING 60 6e ��N
ADDRESS U � I� �
ertified copy.is filed with t cou build ng inspection NUMBER FIXTURE OR ITEM • FEE
WATER CLOSET LOCALVTY t rm pL e Cf
Date Applicant NEAREST
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORK
COMPENSATION INSURANCE SHOWER OWNER 5_Tf
LAVATORY MAIL
(This section need not be completed if the work involved ADDRESS 5,5 0
by the permit is for one hundred dollars ($100) or less.) SINKa
CITY LpA_,PLe C' _• TEL. NO. O
I certify-that in the performance of the work for which this DISHWASHER ` U
permit is issued, I shall not employ any person in any manner CONTRACTOR &10 Ir
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER0
:
ADDRESS Cj (_ L AJ �� �A' F-
Date Applicant SWIMMING POOL RECEPTOR rt V
NOTICE TO APPLICANTIf, after making this Certificate of CITY Cb(JI TEL. NO.0- a
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE r�/ LIC. U)
Compensation provisions of the Labor Code, you must forth- LICENSE NO. `� �Cf CLASS
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked. , GAS SYSTEM OUTLETS DISTRICT NO. PROCESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 P SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- , \ FINAL ,�F VALIDATION
ness and Professions Code, and my license is in full force and V DATE
effect. C
S ' Qco?! FINAL
License Num er tJ [�•,±ia.eClass BY
Contractor t�its
0 I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE
Lie,or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's 0 Address
License Law for the following reason (Section 7031.5, Busi- City Tel. No.
ness and Professions Code):
I, as owner of the property, am exclusively contracting
.Q . A
4
with licensed contractors to construct the project
(Section 7044, Business and Professions Code). # o 0 0 0 0 3
CONSTRUCTION LENDING AGENCY 2 0 0 600
I hereby affirm that there is a construction lending agency _
for the performance of the work for which this perrni i 0 0 0,1600
U
issued(Sec.309 J
Lender's Name 6' -a'�
Lender's Address CQ(_Lk_ kk
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
author' epres tatives of this County to enter upon the
above- y for inspection purposes. p/
Signature of Permittee Date