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Home My Public Portal About5569 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' Compensation Insurance, 76A667A or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ` Certified copy is filed with the county building inspec- ADDRESS tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET �© �7. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 0, CROSS ST. /p COMPENSATION INSURANCE OWNER SHOWER �`�. (This section need not be completed if the work involved by MAIL R,_ � the permit is for one hundred dollars ($100)or less.) LAVATORY Q ADDRESS A (,o% ,- ACI certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner j SINK d,. CITY TEL. NO. so as to become subject to the Workers'Compensation Laws. DISHWASHER ^ F% CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- rj LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be c+� C STATE LIC, deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ✓� (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and m license is in full force and effect. 5 PER SYSTEM 7= y Q FINAL LDATEZ— ( —�3 VALIDATION CQ License Number Lic. Class_,_ `� � 0, \P-k ® �Lry FINAL Contractor Date BY ❑ �, I am exempt under Sec. U 1,11 B.6P.C. for this reason Plan check fee � Date: PLUMBING PERMIT ISSUING FEE$ /3 Signature TOTAL FEE Plan check applicant SINGLE FAMILY t as HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and Pro ssions Code): City Tel. No. a F t i-. as owner of the property, will do the work and the t 1 s t r'„•',F y:'rs -_s 0 structure is not intended or offered for sale (Section 7044, Business and Professions Code). UHf-l`'f` CONSTRUCTION LENDING AGENCY L_•H3 (i3L 1i 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. . t , ,`S E_i sl i s•, ;'s Lender's Name HFI�,,`, M . _. 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 State laws regulating Plumbing, and hereby a orize representatives of this County to enter upon the ve-�inspection purpo es. SEE REVERSE FOR EXPLANATORY LANGUAGE GI Signa ure of Permittee Date