HomeMy Public PortalAbout5634 1/2 MCCULLOCH AVE_Plumbing__ .i .
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WORKERS'COMPENSATION DECLARATION r
/� PLICATION FOR PLUMBING PERMIT
I hereby;affirm that I have a certificate of consent to self ., 78A667A
insur6'"or a certificai'e of Workersr mpensation Insurance, CE'817(REV.8/88)
OF cettified copy thereof(Sec..3 Lab. C.) l COUNTY OF LOS ANGELES DEPT.,,OF PUBLIC W RK§
Policy No. Compo ti
Certified copy is hereby furnished: BUILDING ,
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Cert 'ed copy is filed with f count'building inspec- .
do depart nt. NUMBER FIXTURE OR ITEM FEE
LOCALITY' r'
Date Appligont WATER CLOSET NEAREST ` 64k 1' ,
RTIF CATE OF,EXEMPTION FROM WORKERS' BATH TUB r.-. CROSS ST!,
AF
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work Involved by NiAjL i
the permit Is for one hundred dollars($100)or less.) LAVATORY ADDRESS _ 7�
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK -!- CITY TEL.NO.
so.as to become subject to the Workers'Compensation Laws. DISHWASHER ': • �
CONTRACTO
Date Applicant CLOTHES WASHER ADDRESS
AU e-
NOTICE TO APPLICANT: If, after making :this Certificate of SWIMMING.POOL RECEPTOR
Exerrip'tion, you should liecorrie subject to the Workers' CITY TEL.NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or 'this permit shall be A STATE LIC. rl
deemed revoked:' WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION / DISTRICT NO. i OCESSED BY
I hereby affirm that I am licensed under provisions'of Chapter 9 GAS SYSTEM OUTLETS GV
(commencing w!}h Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code, nd my I! a's.in full force and effect. 5.PER SYSTEM FINAL VA ATION
DATE y (�
License M er Lic. Class
r FINAL
Contractor Dat BY
h
.❑ I am exempt under See. '
B.BP.C. for this reason Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$ C/
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 Address
Law for-the following reason (Section 7031.5,. Business and M 7,0 2 6 A
Professions Code): City Tel. No.,
I, as owher of t)te property,,will do the work and the #,0 0 o 0 0 5
structure is not intendedor offered for sale (Section
7044, Business and Professions Code). ° o 91L 5 0
CONSTRUCTION LENDING AGENCY o,o o 9 k 5 05
Fhereby off irm that there is a construction lending agency for
the performance of the work for which thispermit is issued.
(Sec. 3097, Civ. C.). 2-87
Lender's Name
Lender's Address
I certif that I have read.this application and state that the ,
above orma is correct. I agree to comply with all County
o�dina c s a d tate laws regulating Plumbing and hereby
author! a re Yes ntafives of this County to en r up n the
above- t.i a property for inspection purp es.
r/n� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signat're f Perm ee to