HomeMy Public PortalAbout5528 MCCULLOCH AVE_Plumbing__ � 71
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consent to self in 76A66�A PW 4/87
sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV.8/86)
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) ��.�
Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE
n(� ki/�Applica LOCALITY
Date ✓ WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER
SHOWER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK CITY TEL. NO.
mit is issued, I shall not employ any person in any manner so
as to b come s .ect to the Worke s'Compe s ion Laws. DISHWASHER CONTRACTOR /
Applicant CLOTHES WASHER
ADDRESS
NOTI E TO APPLICANT: If, after making this Certificate of Ex- SWIMMINGPOOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. AOCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATIONoor
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fect. DATE C
License Number Lic. Class V
FINAL IM
Contractor Date BY O
F-
�I am exempt under Sec. W
IL
B.&P.C. for this reason ® U)
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature QdlTOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name -'
Low for the following reason (Section 7031.5, Business and
Professions Code): Address i. ' :q
.
I, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044,
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.). i.;=i="{t
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-mention erty for inspectio purposes.
✓4i SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig ature o Permittee Date