HomeMy Public PortalAbout5634 MCCULLOCH AVE_Plumbing__ • WORKERS'COMPENSATION DECLARATION APPLICATION FOR .PLUMBING PERMIT
I lye�eby?i3ffirm that I have a certificate of consent to self 76A887A
,� p CE 817(REV.8/88)
insure, or a certificate of Workers'Compensation Insurance,
or a certified copy thereof(Sec. 38M, Lab. C.
ny COUNTY OF LOS ANGELES DEPT. OF PUBLIC•W R S
Policy No. Comp
t
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certi .d co is filed with tt' &==p building insec-Aart' spar t. NUMBER FIXTURE OR ITEM FEE LOCALITY
Date Appli4antWATER CLOSET NEAREST
C, ,
CERTI ICATE OF EXEMPTION OM WORKERS'• BATH TUB CROSS ST. •'
COMPENSATION I URANCE SHOWER OWNER
•c.
(This.section need not be completed if the work Involved by MAILr
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS.
I certify that in the performance of the work for which INS' 3_,L`
permit is issued,I shall not employ any person in any manner' SINK CITY .'. TEL.NO'� `'�
so as to become subject'idthe Workers'Compensation Laws. DISHWASHER
CONTRALTO // __-- S?.
Date /►pplicant CLOTHES WASHER ADDRESS /6�
NOTICE TO APPLICANT: If, after making this. Cerfifi¢ote of SWIMMING POOL RECEPTOR
Exemption, you shoWcl become subject to the Workers' CITY TEL.NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply: with such.,provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS (/
LICENSED CONTRACTORS DECLARATIONDISTRIX NCL OCESSED Y
I hereby affirm that I qm licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (/J�
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER d
and Professions Code and my licensp.is in full.force and effect. 5 PER SYSTEM . FINA _ O
VALI ATION �
License Num Lic. Class I$
FIN
Contractor ate v BY . _ W
❑ ,I am exempt un r Sec. IL
B:BP.C. for ih' r as z
• Plan check fee � •
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant y 7 0 2 5 A
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name' '
I hereby affirm that I am exempt from.the Contractor's License Address # 0 0 0 0 0 5
Law for-the following reason (Section 7031.5, Business and l 0 0 9 4,5 0
Professions Code): City Tel. No.
❑ I, as owner of the property,will do.the work and the ® o o,0 9 4,5 Ov
structure is:not Intended or offered for sale (Section
7044, Business and Professions Code). _ Q 5 1 2 s$'7
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 17have read this application and state that the Pool
info tion is ct. I agree to comply with all County
ordinanc nd e w .egulating Plumbing, a hereby
outhoriz pr ent rve f this County to enter Pon t _
above- ti ed op for inspection purpys' .
SEE REVERSE FOR EXPLANATORY LANGUAGE
cit Of
of rmittee Date