HomeMy Public PortalAbout6025 MUSCATEL AVE_Plumbing__ i W<ERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I�ei� rfirm that I have a certificate of consent to self in- 26A667 DPW a/87
Y' 76A667A
sere,or a c@rtific6te of Workers'Compensation Insurance,or a CE 817(REV.8/86)
certified copy thereof(Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No, Company
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING .�
Certified copy is filed with the county building inspection ADDRESS �8 C �i��-�
department. NUM ER FIXTURE OR ITEM @ FEE LOCALITY`�.?rs_ JP�� G I^�c
Date Applicant WATER CLOSET(TOILET) NEAREST � �`�
CERTIFICATE OF EXEMPTION OM WORKERS'
/ BATH TUB Q CROSS ST.�C.t�,C�`
COMPENSATION INSURANCE SHOWER OWNER V
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY d ADDRESS I JLL
I certify that in the performance of the work for which this per- SINK Q
mit is issued, I shall not employ any person in any manner so CITY 9 TEL. NO.
as to become subject to the Workers'Compensation Laws. DISHWASHER d C"`pV_ �
, ��+
/y CONTRACTOR � �
Date Applicant CLOTHES WASHER v ADDRESS --``
NOTICE TO APPLICANT: If, after making this Certificate of Ex- V
emption,you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR CITY
sation provisions of the Labor Code,you must forthwith comp- TEL. NO.
P Y P- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER O LICENSE NO. � CLASS ���� 36
LICENSED CONTRACTORS DECLARATION DISTRICT N CLASS D BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER `
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL -f � (, VALIDA N
fect. DATE�j GO
License Number Lic. Classa
-� � Ic
`
Contractor &"45 Date X72-8 B j �' X 9 4 11.9 A d
❑ I am exempt under Sec. #'o 0 0 0 0 5 All
06
B.BP.C. for this reasonPlan check fee ® II o o 5 a 5 0 a
Date: PLUMBING PERMIT ISSUING FEE$ s o o o 5 a 5 0
U
Signature
TOTAL FEE 0 IL 2 2-8 8
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and
Professions Code): Address
I, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044,
Business and Professions 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 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 representatives of this County to enter upon the
above-mentioned proper for' spection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ig ature of Permittee Date