HomeMy Public PortalAbout4815 HALLOWELL AVE_Plumbing__ WORKERS'COMPENSATION�DECLARATION 20.0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consept to self in- 76A667A
sure,or r,certificate of Workers'Cbmpens tion Insurance,or a CE 817(REV. 8/86)
certified co thereggo//f (Sec. 3800, Lab. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy N6. /v`� Company
Certified copy is hereby furnished.
_ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING / f ��O G
Certified copy is filed with the county building inspection ADDRESS G!J 4:�--L,
department. NUMBER FIXTURE OR ITEM @ FEE
/ �i LOCALITY
Date [/ Y Applicant s WATER CLOSET(TOILET) / NEAREST C'
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB 1 CROSS ST,
COMPENSATION INSURANCE OWNER ����s
SHOWER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) 3 LAVATORY S6 ADDR
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so SINK 7 6 .CITY �y TEL.�YOj
as to become subject to the Workers' Compensation Laws. DISHWASHER
CONT /jJiC ✓�Ii�iC�/c!//✓� yS
Date Applicant CLOTHES WASHER 5`10 /
NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDREW& � /l e&e, .I� •
SWIMMING POOL RECEPTOR
emption, you should become.subject to the Workers'Compen-
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM CITY
ly with such provisions or this permit shall be deemed revok- STATE �7p / �j G UC.
ed. WATER HEATER Sp LICENSE NO. / /d y CLASS - -a to
LICENSED CONTRACTORS DECLARATION 5 Q DISTRI T NO. ROCES E
I hereby affirm-that I am licensed under provisions of Chapter GAS'SYSTEM OUTLETS
9(commenci6g with Section 7000)of Division 3 of the Business OUTLETS OVER S IF
fed Professions Code, and
rmmyyllicense is in full force and ef- 5 PER SYSTEM FINAL/.-,:,Y,_C�� V LID ON
�// d O el'? � DATE 0
License Number Lic. Class 0
�jJ
FINAL,[f U
fyvU-�' Q
Contractor Q�/ � Date / a�- BY p
❑ I am exempt under Sec.
LU
B.&P.C.'for this reason Plan Check fee. ► g
Date: PLUMBING PERMIT ISSUING FEE$ �d
Signature TOTAL FEES, j d
SINGLE FAMILY
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 "' s
Professions Code): Address41�°a he* L-.
3307
I, as owner of the property, will do the,work and the City Tel. No. r �,
structure is not intended or offered for sale(Section 7044, •L ITEMS
Business and Professions Code). , 125 .50
CONSTRUCTION LENDING AGENCY4 125 ^11
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued r;HANGL °1111
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address AM8=4!1
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
ob ve-mentioned property for inspection purposes.
-SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee 11— Date