HomeMy Public PortalAbout5638 MCCULLOCH AVE_Plumbing__ 7.�vORKE COMPENSATION DECLARATION VV`�PPL:ICATION FOR PLUMBING PERMIT
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I•her�by, i�rm .t Of I have a aertificate.of consent to self 78A887A
"�;.(,Pisure,��•a certificate of Vyorkers'Compensation Insurance, CE'817(REV.8/86)
'+ or.cicf'tified copy thereof(Sec. 3 Lab, C.)
�` COUNTY OF LOS ANGELES DEPT.,OF PUBLIC WO KS'
Poliq No. Compo t
❑' Certified copy,is hereby furnished.
. „ BUILDING•, '
FOR APPLICANT TO FILL IN(PRINT OR.TYPE) ADDRESS, t
Certifi copy'is filed with the c unty building,inspec-
T tion artme t. NUMBER FIXTURE OR ITEM FEE LOCALITY C s
f
WATER CLOSET
Date pli4anT _ — NEAREST
CROSS ST..
CERTIF TE OF EXEMPTION FROM WORKERS' BATH TUB
COMPENSATION INSURANCE i OWNER t
SHOWER
(This section.need not.be completed.if the.work Involved by
• MAIL �
the Permit is for one hundred dollars($100)or less.) LAVATORY /' ADDRESS 0- 16 0
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY !� TEL NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER.
CONTRACTOR
Dale, Applicant' CLOTHES WASHER ADDRESS
SWIMMING TO-APPLICANT: If, .after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the'Workers' CITY TEL.NO.
Compensation provisions of the Labor.Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER. LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCE BY
'1 GAS SYSTEM OUTLETS /ti
• I hereby affirm that I am licensed under provisions of Chapter 9 (J
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,.and my license's in full force and effect. 5'PER SYSTEM FINALALIDATION
DATE
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License Number Lic. Class ` 3 99
L✓ F L
Contractor `�� Dote 7 �
: C7
❑ 1.am exempt under See. IL
1, ' �7029A
8:8F.C. for this reasonplan check fee # 0.0 0.0 0
Date: PL'UMBING'PERMIT ISSUING FEE$ 1.-o 0 9 4.5 0
Signature
TOTAL FEE o - - 94,505
'
,
Plan check applicant,
SINGLE FAMILY• 05-12-87
HOME OWNER-BUILDER DECLARATION Name
1 hereby affirm that I am exempt from the Contractor's License Address
,I Law for-the following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
❑ I, as owner of tAe property,will do the work and the
structure is not intended or offered for sale (Section ,
7044, Business and P.rofessiohs 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 hav . ead this application and state that the ,
above informatio correct. I agree to comply with all County L
ordinances.ancl 03fte I regulating Plumbing, and hereby
authorize rept nt rve of this County to enter up n the
above-mentio rope y for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signotur Per Dc/
e