HomeMy Public PortalAbout5936 LOMA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING -PERMIT
_
I`cher jby,affirffl''0hr_,C I h6ve a certificate of corisent to self 20-0026_DPW 6/87
;nsure; or a certificate of Workers' Compensation Insurance, 76A667A-
on.o certified copy thereof (Sec. 3800, Lob... 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.501 NUMBER FIXTURE OR ITEM @ FEE LOCALITY
WATER CLOSET ��(I
Date. Applicarit l '/(^,V,,/� NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
rV
COMPENSATION INSURANCE ?/ SHOWER OWNER L
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100)or less.) LAVATORY ° MAIL
ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER i t / ADDRESS
NOTICE TOAPPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEMRAA~A � 2 /
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. / WATER HEATER LICENSE NO. CLASS G��
LICENSED CONTRACTORS DECLARATION DISTRICT PRO D BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM, FINAL �j ALIDATION
G DATE ��/Z �
License Number L211 /_Lic. Class 0
U
.r.�
FINAL 0:Contractor "�s / �� Date —sv' FI 0'
❑ 1 am exempt under Sec. W
B.BP.C. for this reason
Plan check fee ® Z
Date:
PLUMBING PERMIT ISSUING FEE$ 1
Signature
TOTAL FEE men
Plan check applicant
SINGLE FAMILY 5
HOME OWNER-BUILDER DECLARATION Name
I hereby off irm that I am exempt from the Contractor's License ACCT.T
Law for the following reason (Section 7031.5, Business and Address r� � Li ol�l
7.�Y l 4
Professions Code): City Tel. No. .- r-
❑ 1, as owner of the property, will do the work and the ' ITEtNS-
structure is not intended or offered for sale (Section ® 1'I.ITA� 17113' ® lOO
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CHECK �{�,'�li
I hereby affirm that there is a construction lending agency for CHANGE oco
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
i1�10(J-►; G 1 5/161191
Lender's Address ('I'04. . -. 1..... Alf S
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 rep sentotives of this County to enter upon the
above-menti d property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permitlee Date