HomeMy Public PortalAbout5636 MCCULLOCH AVE_Plumbing__ APPLICATION FOR PLUMBING PERMIT
��`'• ''• •WORKERS'COMPENSATION-DECLARATION
:71 he;* affirm that I have a certificate of consent to self 76A667A -Iul
" insvre, or a certificate,of Workers;. ompensation Insurance, CE 817(REV.8/86)
or a certified copy thereof(Sec. , Lab. C.)
COUNTY OF LOS ANGELES � DEPT. OF QUBLIC WORKS'
Policy No. Compa y , , •
11
Certified copy is hereby furnished: BUILDING
Cent fed co y is filed FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS with the county building' pec- '
tiohldeparynenti. NUMBER FIXTURE OR ITEM @ FEE
(� ,� _P WATER CLOSET LOCALITY �`.•
Date 'q Appli4ant �t NEAREST r
CERTI14CATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. -e_
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by MAIL
�Lo
the permit is for one hundred dollars($100)or less.) LAVATORY i ADDRESS
I certify that in the performance of the work for which this SINK r CITY /f TEL NO.
permit is issued,I shall not employ any person in any manner , �/t -
so as to.become subject to.the Workers'Compensation Laws: DISHWASHER
CONTRACTOR
Date ApplicantCLOTHES,WASHER - '— ADDRESS
Vj
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, .you should become subject to the Workers' CITY NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE, LIC.
deemed'revoked. WATER HEATER LICENSE NO. / CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT Ngy/ PR D BY
I:hereby affirm that I am licensed under provisions of Chapter 9 ••
` GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and m lice full force and effect. 15 PER SYSTEM FINAL VALID TION
DATE' O
License INber' Lie. Class
FINAL
Contrac o. Date�;h,7 IF
BY CCC��i
I am;exempt under Sec.
B.BP.C. for this r o
Plan check fee . ,nate—PLUMBING PERMIT ISSUING FEE$
Signature I&==11& - Q
TOTAL FEE
SINGLE FAMILY
Plan check applicant
- '
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 A7 0 2 7 A
Professions Code): City Tel. No.
❑ I, as owner of the property,.will do the work and the # 0 0 0 0 0 5
structure is not Intended or offered for sale (Section :1 o a 94,50
7044, Business and Professions Code). ,
CONSTRUCTION LENDING AGENCY0 o 094,505
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued 0 5 12—.- 87
(Sec. 3097, Civ: C.).
Lender's Name
Lender's.Address
1 certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and ate law ulating Plumbing,and hereby,
authorize rep r entati this County to enter upon the
above-menti ed pr e!P?c
r inspection purpose
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatur.,of Per Dat