HomeMy Public PortalAbout5757 GOLDEN WEST AVE_Plumbing__ 1
t�herb y,WORKERS'
IOMPe aS TION DEtificate DECLARATION
self in_ 20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT
76A667A
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sure,or a certificate of Workers'Compens do Ins ce,ora CE 817(REV. 8/86)
certified copy thereof (Sec. 3800, L.
C .
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company f
E 4
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
Certified copy is filed with the co ty uilding inspection ADDRESS
departVent Ee
NUMBER FIXTURE.OR ITEM @ FEE
LOCALITY f
WATER CLOSET(TOILET)
Date Applica NEAREST
/CERTIFICATE OF EXEMPTION FROM'WORKERS' j BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER GLe� L:✓
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CITY TEL. NO.
as to becom su 'ect to the Workers' Compensation Laws. DISHWASHER
CONTRACT
Date Applicant CLOTHES WASHER ADDRESS
NOT TO PPLICANT: If, after-making this Certificate of Ex- SWIMMING POOL RECEPTORr
emption, you should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM,
ly with such provisions or this permit shall be deemed revok- STATE r LIC.
ed. WATER HEATER LICENSE NO. �G,J CLASS
LICENSED CONTRACTORS DECLARATIONGASSYSTEM OUTLETS DISTRICT NO. OCESSED B�
I hereby affirm that I am licensed under provisions of Chapter
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINA VALIDATIO >'
fect. �f DATE 9L
License Number b ` Lic. Class Q
FINAL IM
ContrQef ^- Date '
BY
I am exempt under Sec. P LU
- �873,8A
B.&P.C. for this reason Plan check fee ' ► # a o o o ° 5 g
Dot PLUMBING PERMIT ISSUING FEE$ p
r i2' _ ° ° G Q 5
—� TOTAL FEE
.Sign
SINGLE FAMILYr ° ° ° 4 Q.5 0�
HOME OWNER-BUILDER DECLARATION Plan check applicant
1 hereby affirm that I am exempt from the Contractor's License Name O 1.-1 1 -88
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 sole'(Section 7044,
Business and Professions Code).
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 I have read this application and state that the
above information is correct. I agree to comply with all County ,
ordinances and Stat laws regulating Plumbing, and hereby
out ize represe tives o is dunt'y to enter upon the
a v ntione aper or in taction purpo es.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permitte D to