HomeMy Public PortalAbout5632 MCCULLOCH AVE_Plumbing__ WORKERS'COMPENSATION„DECLARATION - APPLICATION FOR PLUMBING PERMIT
�l h�Yf afflrm that I have a certificate of consent to self 7BA887A
y
N-hsure,or a certificate"of Workers'Compensation Insurance, CE 817(REV.8/88)
or'a certified copy thbreof(Sec. Lab. C.)
Policy No. Comp COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ••�
Certifi d co y is filed with the county buildin inspec- ADDRESS �G_— �. • �'Q C�
do Depart nt. NUMBER FIXTURE OR ITEM @ FEE LOCALITX' �-1
. ,
Date r Appli4ant ' Ste, WATER CLOSET NEAREST•
CERTI CATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.,t I
COMPENSATION INSURANCE OWNER �:�
(This section need not be completed if the work Involved by SHOWER MAIL `
the permit Is for one hundred dollars($100)or less.) LAVATORY ADDRESS, C �
I certify that in the performance of the work for which this ,
permit is issued, I shall not employ any person In any manner ! SINK CITY - EL.NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
�.�. CONTRACTORS S
Date Applicant CLOTHES WASHER • ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of I 'SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY C07, TEL.NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATELIC.
deemed revoked. WATER HEATER LICENSE N CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT N PR7E% BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �1
(commencing wi+h Section 7000)of Division 3 of the Business OUTLETS OVER C
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FIN _Q VALID N C
Da
.License Nu ber Lie. Class � �
Q FI C
Contracto ' Date 4 i LL
Eli am exempt under Sec.
U
B.BP.C. for this r son Plan check fee ® a
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant 7 0 2 4
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
1 hereby affirm that I am exempt from the Contractor's License # 0 0 0 0 0 5
Law for.the following reason (Section 7031.5, Business and Address
Professions Code): City Tel. No. 1 ,
I x•1..00;50
❑ I, as owner of the property,will do the work and the ( `'o 01, 0 Q.5 0-
structure is not intended or offered for sale (Section L- �,
7044, Business and Professions Code). o S 12 -87'
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 ve read this application and state that the
above inform n is correct. I agree to comply with all County
ordinances Stat s regulating Plumbing, and hereby
authorize r e tali. s of this County to enter u nth
above- on d pr erty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ure of P i ee DOW