HomeMy Public PortalAbout4816 HALLOWELL AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I"hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compens6tion Insurance, 76A667A
of a certified copy the^r�eof�Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No , I Q_70 6Company I �*
❑ Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDINGJJ
Certified copy is filed with the county building inspec- ADDRESS
1 n d artment. NUMBER FIXTURE OR ITEM @ FEE j
I ttLOCALITY V cJ '
Date Appli4ant � +� WATER CLOSET V) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKER BATH TUB O CROSS ST. Q l,'
COMPENSATION INSURANCE SHOWER OWNER g L.0
(This section need not be completed If the work Involved by �tMAIL _
the permit Is for one hundred dollars ($100)or less.) LAVATORY 0 ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK ! '� o CITY �� TEL. NiO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ®
ADDRESS
NOTICE TO APPLICANT: If, after making this Cer ificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR -
CITY \ TEL. NO. 9�
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM Cl
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. a WATER HEATER O LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICTN TxL
I hereby affirm that I am licensed under provisions of Chapter 9 { GAS SYSTEM OUTLETS ��
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINA VALIDATION I
DATE ti Q
License Number Lic. Class
FINAL
Contractor Date BY
❑
I am exempt under Sec. 0�
B.&P.C. for this reason ® �°
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ �� a
Signature
TOTAL FEE
Plan the applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name � _ AL
I hereby affirm that I am exempt from the Contractor's License ACCTA
Law for the following reason (Section 7031.5, Business and _ARAddress '1 307 76.501
Professions Code): City Tel. No. 3= V.:.� ITEM
❑ I, as owner of the property, will do the work and the J I
structure is not intended or offered for sale (Section TOTAL .76;®50
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CHECY� 76`50
I hereby affirm that there is a construction lending agency for CHANGE Goo
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name 0000-0001 8/25/8
Lender's Address 5005 f AM 8:i?
1 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 repre'sentaAvesA this County to enter upon the
a ve-mentioned pr er r in pectionrposes.
�� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Perrpi4ee Da e