HomeMy Public PortalAbout4964 MCCLINTOCK AVE_Plumbing__ I pWORKERS',COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
ff�irm thaty have a,certificate of consent to self 76A667A
Sr a certificotb of Workers'Compensation Insurance, CE 817(REV 10 81)
or a cr..'copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Poric(�N YXCTCompan2=
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
OpCertified copy is filed with the county building inspec- ADDRESS �✓�
tion department. NUMBER FIXTURE OR ITEM @ FEE
�� G�CC'' LOCAL
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Data —�gfzAppligant lnw x WATER CLOSET
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB r CROSS ST.
COMPENSATION INSURANCE SHOWER r OWNER
(This section need not be completed If the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY A ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO.��Sp
so as to become subject to the Workers'Compensation Laws. t DISHWASHER
CONTRACTOR �
Date Applicant ' CLOTHES WASHER A
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY TEL.NO.
Compensation provisions of the Labor Code, you must forth- WN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE �+ LIC.
deemed revoked. WATER HEATER / .�. LICENSE NO. 4�417J Q$ CLASS
LICENSED CONTRACTORS DECLARATION f DISTRICT NO. PRqCESSED 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
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N 0
DATE97-7—gr
License Number �1-C �g Lir. Class
/ FINAL O
Contractor Date
❑ I am exempt under Sec. UPI
B.&P.C. for this reason ;21 0 2 5 A
Plan check fee �
Date: PLUMBING PERMIT ISSUING FEE$ ,�� /' 0 0 0 0 0 5
Signature TOTAL FEE ) 0 0 8 a 5 O
Plan check applicant eye 0/% C, 0 0 0 88.5 0 26
SINGLE FAMILY 11.07-34
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License liG
Law for the following reason (Section 7031.5, Business and II AddressS
Professions Code): Cityi—'—le �� Tel. No. 577pV—CSO
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section 0017044, 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
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
above-menti d roperty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ign t Date