HomeMy Public PortalAbout5210 MUSCATEL AVE_Plumbing__ t •':nRKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
t n that I have a certificate of `consent to self 70A667A
ir,�,rc a 4,..rtificate of Workers'Compensation Insurance, CE 817(REV.8/86) u
sir a1 -ot.fivd •bpy thereof(Sec. 3800, Lab. C.)
polity nab�OrG9�Company A COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
❑ Cortifiad copy is hereby furnishod. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
LCernfied copy is filed with the county building inspec-
tion department.
�(/�7 /dam NUMBER FIXTURE OR ITEM @ FEE LOCALITY ��!9
Date ✓ Appil4an ,�� °-� WATER CLOSET
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' ¢ .. BATH TUB ►y `' CROSS ST.
COMPENSATION INSURANCE ' OWNER
(This section nood not bo complotod if the work Involvod by SHOWER 10 j;
the permit Is for one hundrod dollars($160)or loss.) ) a� MA
LAVATORY IL
' t'� L'+r ADDRESS
1 certify that in the performance of tho work for which this
permit is issued, I shall not employ any person in any manner / SINK y ' CITY o TEL. N��9R;—f it J
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
ie �� �mx-1
Date Applicant CLOTHES WASHER ADDRESS �+
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR w
Exemption, you should become subject to the Workers' CITY �e TEL. NO.-
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM "
with comply with such provisions or this permit shall be STATE � � �� LIC.
deemed revoked. WATER HEATER v LICENSE NO. CLASS le
LICENSED CONTRACTORS DECLARATION DISTRICT NO SSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL G
y_/_ VAL16XTION
V, DATE
License Number 17 0 Lir. Class
Roy'?
FINAL /1�►� C
Contractor BY
I am exempt under S
_ G -5 5. :;to A
B.BP.C. for this reason Plan check fee ;t o u a o o 5
Date: PLUMBING PERMIT ISSUING FEE$
Signature � - j c c 8 2.;::I
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name o
1 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 proporty,will do the work and the
structure is not intended or offered for sale (Section
it-
7044, Business and Professions Code). op
CONSTRUCTION LENDING AGENCY
I hereby affirm that thore 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 have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize roprosontativos of is County to enter upon the
abo honed property r inspoction purposes.
BEE REVERSE FOR EXPLANATORY LANGUAGE
igna o of Permittee Date
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APPLICANT FlLG IN mgAYILY OUTLINED PORTION ONLY•: ,!Y'•, C/
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DEPARTMENT 'OF B 770M.FOR.{
;A COUNTY OF LOS ANGELESPI:UMBING,r � .
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