HomeMy Public PortalAbout5312 MCCULLOCH AVE_Plumbing__ V 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'Compe sation Insurance, 76A667A
or a certified topy the o 3800,
5r�� ��) /^sem COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Policy Ni pony I�Y[11J,�_�_�m
❑ Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) 2 �
Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM 0 FEE
q LOCALITY
Date Applicant
WATER CLOSET 50 a,2b NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CROSS ST.
COMPENSATION INSURANCE SHOWER ls�oe OWNER J1®
(This section need not be completed if the work involved by MAIL p
the permit is for one hundred dollars($100)or less.) LAVATORY C f^J ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TELN91
so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR _ I
15 1
Date Applicant CLOTHES WASHER Q ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL.NO6. 12a.:,5
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE ` LIC. /
deemed revoked. WATER HEATER LICENSE NO. CLASS �/
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED
B
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETSa�/ Ir/G7/41✓
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER a
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL =
J ]� Q VALIDATION a
License Number 20
i . Class �/ DATE L
" / FINAL C
Contracto BY C
❑ I am exempt under Sec. C
B.BP.C. for this reason B
Plan.check fee ►
Date: PLUMBING PERMIT ISSUING FEE$ D
Signature _
TOTAL FEE
Plan check applicant
SINGLE FAMILY =
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License 1
Address �T (.I Air
Law for the following reason (Section 7031.5, Business and - i—E
Professions Code): City Tel. No. ,3.s,j,gii/ _ ,CC
❑ I, as owner of the property, will do the work and the 1 1 1 GM1
structure is not intended or offered for sale (Section ®
O TAL 135.00
7044, Business and Professions Code). TOTAL
CONSTRUCTION LENDING AGENCY CHECK
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued t.;-( i tzL I_IIJ
(Sec. 3097, Civ. C.).
u000--00011 5r _wlI
Lender's Name .t
Lender' 1177 1 An11a 1`�
ertify that I h ve read this a plication and state that the
above information is correct. I a ee to comply with all County 1111111
inances and State laws re ating Plumbing, and hereby
out a representatives t s C+ounty to enter upon the
above- ntioned property for nspecti n purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Per tte Date