HomeMy Public PortalAbout5525 GOLDEN WEST AVE_Plumbing__ ryVORKERS'COMPENSATION DECLARATION ,
20-0026 DPW 4/87 APPLICATION FOR PLUMBING'-PERMIT
I hereby, affirm that I have a certificate of consent to self in- 76A667A
sure,or a certificate of Workers'Compensation Insurance,.or'a CE 817(REV. 8/86)
certified copy thereof (Sec. 3800, Lab. C.) I . fl
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. ,_Company "
Certified AR py is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING A /
Certified copy is filed with the county building inspection' ADDRESS 0--2-3— (5Zo
NUMBER FIXTURE OR IT LOCALITY
- - department. @. FEE
NEAREST +tet le �y
Date Applicant WATER CLOSET(TOILET) /
V
CERTIFICATE OF EXEMPTION FROM WORKERS' Z, BATH TUB 00 CROSS ST.
- COMPENSATION INSURANCE / om OWNER
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,(This section need not be completed if the work involved by SHOWER
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the permit is for AIL
Crone hundred dollars (;100)or less.) LAVATORY Uv ADDRESS e /5®A J�.
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so SINK CITY w TEL. NC,.2
S)1.7 L�''
e a,
as'to become subject to the Workers' Compensation Laws. DISHWASHER dd
CONTRACTOR
�
Date ` -"- lee Applicant CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT: If, after making this'Certificate of Ex- SWIMMING POOL RECEPTOR "
emption,you should'become subject to the Workers'Compen-
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall,be deemed revok-. STATE LIC.
ed. WATER HEATER IM LICENSE NO. CLASS
LICENSED CONTRACTORS.DECLARATION DISTRICT NO. PROCE D Y
I hereby affirm that`I am licensed under provisions of.Chdpter / GAS SYSTEM 40-OUTLETS r1'
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and.my license is in-full force and ef- 5 PER SYSTEM ,l FINAL VALID ION
fect. 1�✓ (� DATE O
C^i.
License Number Lic. Class O
FINAL
Contractor Date BY O
VV am exempt under Sec: 7D �, 5 Ly
B.&P.C. for this reason pop.Plan check fee' g
Date: PLUMBING PERMIT ISSUING FEE$ 9 0 I{ 9 A o
Signature TOTAL FEE
SINGLE FAMILY plan check applicant
#.o o 0 0,0 5
a
HOME OWNER-BUILDER DECLARATION PP
hereby affirm that I am exempt from the Contractor's LicenseName ,� y ) ° 1 0 a 50
Law for the following reason (Section 7031.5, Business and —`
Professions Code): Address 3 �'� �T o o 1 0 0,5 0
yr,�v'O 6� 1
I, as owner•of the property, will do the work and the City. �.� Tel. 02,25-88
structure is not intended or offered for sale(Section 7044;
Business and Professions Code).
oil
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
Lender's Address
I certify that'd have read this application and state that the ,
above information is correct. I agree to comply.with all County
Poo-
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
Signature of Permittee Date