HomeMy Public PortalAbout5724 MUSCATEL AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION 7GA667A
hereby affirm that I have w certificate of consent to self Ice en (2-801 APPLICATION FOR PLUMBING PERMIT
sure,or a certificate of Workers'Compensation Insura ce,or
e ified co y th 3800, b.C.)
Q'� COUNTY OF LOS ANGEL! f ND SAFE Y
N
3 icy o. C
C rifled copy is hereby furnished. /�/ O ! FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING `�
ADDRESS /
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM ® FEE
department. WATER CLOSET LOCALITY nr}� �
,)ate Applicant NEAREST —7
_ BATH TUB CROSS ST. / v�L� '�S
CERTIFICATE OF EXEMPTION FROM WORKERS' �g
COMPENSATION INSURANCE SHOWER OWNER v y
MAIL
(This section need not be completed if the work involved LAVATORY ADDRESS }a
by the permit is for one hundred dollars ($100) or less.) SINK CITY TEL.NO. 0
U
I certify that in the performance of the work for which this
' permit is issued, I shall not employ any person in any manner DISHWASHER CONTRACTOReC7_ L1-OAJf Z ,66: O
so as to become subject to the Workers'Compensation Laws. CLOTHES WASHER ADDRESS I • /`s _�//�, � W
Date Applicant SWIMMING POOL RECEPTOR �a a
NOTICE TO APPLICANT: If, after making this Certificate of CITY C ,Jr TEL.NO. —011W N
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE f �7 LIC. ��
Compensation provisions of the Labor Code, you must forth- WATER HEATER LICENSE NO. /(��p � C ASS 1 , j�
with comply with such provisions or this permit shall be
deemed revoked. GAS SYSTEM OUTLETS �� ` DISTRICT-NO. P OCESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER �J' ��77OQyy
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM.
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL q i' VALI TION
ness and Professions Code, and my license is in full force and DATE ,j,9-a
effect.
License Number Lic.Class FINAL
License
Contractor Date /
ElI am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ 7
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE
Lic.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Address
License Law for the following reason (Section 7031.5, Busi- City Tel.No.
ness and Professions Code.):
F] I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project X 3 9 1-4A
(Section 7044,Business and Professions Code).
# 000005
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency 2 ° ° 1 2 5 0
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.). c ° ° 1 2 5 0 i'i
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. SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned property_ spection purposesy
Signature of Permittee Date i