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HomeMy Public PortalAbout4836 HALLOWELL AVE_Plumbing__ .� WORKER'S COMPENSATION DECLARATION 20 76-0026 A667A PW 9/89 APPLICATION FOR PLUMBING PERMIT I hereby af99rrr,that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab. C.) ��.� 1 Irk COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No. Company ❑ Certified copy is hereby furnished. �--�/ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING LJ Certified copy is filed with the county building inspection ADDRESS department. u� NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date M-'2.') " 5-_�5 Applicant!,1 •-� WATER CLOSET NEAREST �a CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. ASSESSOR COMPENSATION INSURANCE MAP BOOK PAGE PARCEL (This section need not be completed if the work involved by the SHOWER permit is for one hundred dollars($100)or less.) OWNER LAVATORY 1 certify that in the performance of the work for which this permit MAI L ' ` v is issued, I shall not employ any person in any manner so as to SINK ADDRESS become subject to the Workers'Compensation Laws. ®\ L/ DISWASHER CITY / TEL.NO. ®�w Date Applicant CLOTHES WASHER C� NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR L Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS �1 provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM J, LICENSED CONTRACTORS DECLARATION CITY TEL.NO C �- I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER ®. STATE LIC. (commencing with Section 7000) of Division 3 of the Business and GAS SYST 5 UTLETS /-- LICENSE NO. © �4e CLASS ��d Professions Code, and my license is in full force and effect. OUTLETS OVER 72 DISTRICT NO. PROCESSED BY 5 PER SYSTEM G^L' a�tJ License Number S��0 S� Lic.Class 2"b I-- FINAL DATE 1,,,, VALIDATION l � Contractor 9A� �—Date 2-'Z� -�� 4. _ C0 ❑ FINAL v I am exempt under Sec. - BY B.&P.C.for this reason Plan check fee , ! Date: PLUMBING PERMIT ISSUING FEE$ Signature � TOT AL '�' �"'� �•,_r ❑ TOTAL FEEl :"f-�Ef 4 t -r,�._, Plan check applicant _rq E7 SINGLE FAMILY Hi r"1 HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Address }j_s_{'�tl '=,_. Code): ❑ City Tel. No. Pr; 1,as owner of the property,will do the work and the structure = ` is not intended or offered for sale (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 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 above-mentioned property for inspection ur SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Perhiitteb Date