HomeMy Public PortalAbout5632 1/2 MCCULLOCH AVE_Plumbing__ WORKEfts'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
t*, I heretby affirm that I have a certificate of consent to self 76AS67A
insure, or a cbrtificate of Workers' mpensation surance, CE 817(REV.8/86)
or a certified copy therdof(Sec. Lab. C.)
Policy No. Comp � COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
/L' a
Certified copy is hereby furnished. BUILDING -ry /y J��/�'
7 FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS ` C U�°�'a "
Cert' ed py is filed with JFM
b i Ing inspec-
ti ep tment. NUMBER FIXTURE OR ITEM @ F E LOCALITY
WATER CLOSET �
Dat Appli4ant tNREST
C IFICATE OF EXEMPTIOWORKERS' BATH TUBSS ST. �t��COMPENSATION NCE SHOWER NER �..�� �/
(This section need not be complehe work involved by
MAIL
the permit is for one hundred.dollars($100)or less.) LAVATORY ✓ ADDRESS J
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY O , TEL.NO. `
so as to become subject to the Workers'Compensation Laws.
DISHWASHER — CONTRACTOR �
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS
100 al—
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY TEL.NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER by LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT N -W P D BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS r,�-
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER c
and Professions Co ,a d y lice n full force and effect. 5 PER SYSTEM FINAL VALIDC
_ ATI
r' DATF
License Num Lic. Class L
FIN F
Contractor Date BY i
❑ I am exempt under Sec. a
B.BP.C. for this reason 2
Plan check fee , ;27028A
Date: PLUMBING PERMIT ISSUING FEE$ # 0 0 0 0 0 5
Signature
TOTAL FEE 0 1 e1v I o - 94,50
SINGLE FAMILY Plan check applicant o'o 0 94.505
HOME OWNER-BUILDER DECLARATION Name Q 5 ,2—8 7
I hereby affirm that I am exempt from the Contractor's License Address
Law for-the following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
❑ I, as owner of the property,.will do the work and the
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.).
Lender's Name
Lender's Address
I certify that I h read this application and state that the
above informati is corre I agree to comply with all County
ordinances an tate regulating Plumbing, and h reby
authorize re se tive of this County to enter u the
above-ment' a prop rty f r inspection purpose
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Sign a of Per_Vpbe p6te