HomeMy Public PortalAbout5241 MCCLINTOCK AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
11,ereby 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.❑ BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS —1 I�L ill fc -1���(j SCJ
Certified copy is filed with the county building inspec- NUMBER FIXTURE OR ITEM @ FEE
tion department. LOCALITY `i" �(`li -+�
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER q �
(Thissectionneed not be completed Ifthe work Involved by MAIL -� 1 ft
A A L q -,�-
the permit is for one hundred dollars $100 or less. LAVATORY ADDRESS Hl rr�l'_& /°Cf/t 2
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY a1A1 TEL. N 3Z
so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
1 hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS O D
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER O
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL ; VALIDATION
DATE
License Number Lic. Class C
FINAL
Contractor Date BY C
❑ 1 am exempt under Sec.
LL
B.BP.C. for this reason ►
Plan check fee U.
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE a�J
Plan check applicant -
SINGLE FAMILY D�U `b`7l
HOME OWNER-BUILDER DECLARATION Name 7 `Jv7 . .
I hereby affirm that I am exempt from the Contractor's License f
Law for the following reason (Section 7031.5, Business and Address 522.(1 w 33[1-_,
Profs ions Code): Cit M CLA Tel. No. ,
lJ I, as owner of the property, will do the work and the L L I�'-
structure is not intended or offered for sale (Section , 1}II k; -a-k, 0 50
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY '-ijlGl•i, tf,o:,I:
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CH --
fiNGE
(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
uthor' a re resents' es of this County to enter upon the
ov ione rty for inspection purpos
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signaturef Permittee D to