HomeMy Public PortalAbout6258 MUSCATEL AVE_Plumbing__ WORKER'S COMPENSATION DECLARATION 7BAS87DPw9189 APPLICATION FOR PLUMBING PERMIT IJ
76A587A
I hereby affirm.that I have a certificate of consent to self insure,
or a gertificate of Worker's Compensation Insurance,-or a certified
copy therWy
.)
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
P011oy N� mpact
❑ Curnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with thecounty building insp c ADDRESS
�partment. a/ NUMBER FIXTURE OR ITEM l0 FEE LOCALITY
Date ppiicant WATER CLOSET
Q NEAREST
CERTIFICATE OF EXEM ROM WO CROSS ST.
COMPENSATION INSURANCE BATH TUBASSESSOR
/
(This section need not be complete a work Involved by the SHOWER
MAP BOOK �� PAGE Q PARCEL
permit is for one hundred dollars($100)or less.) LAVATORY OWNER 1
I certify that in the performance of the work for whi s permit
Is issued, I shall not employ any person in Awrifanner so as to SINK MAIL
become subject to the Workers'Comps n Laws.
DISWASHER CITY TEL.NO.
d
Date piicanl CLOTHES WASHER
NOTICE TO APP NT: If, after making this Certificate of CONTRACTOR
Exemption, o . ould become subject to the Workers'Compensation SWIMMING POOL RECEPTOR AD
provisions the Labor Code,you must forthwith comply with such
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION WATER HEATER CI � L a
I hereby affirm that I am licensed under provisions of Chapter 8
(commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS LICE SE NO CLASS V
STTE —7 LIC.
Professions Code,and my license is in full force and effect.
OUTLETS OVER DISTRICT N PROCESSED BY
5 PER SYSTEM
License Number / 4 Lic.Class O.All, F 1; (J(/
I11.0� n■ � FINAL VALE W
��,� Y /(eW�J4af� Z DATE 7 22. CL
Contractor (-/�^ T ` 2• J ^ . R:IL'i n v CL
❑ I am exempt under Sec. 4 gy AL ,r W 19e-5.'
B.&P.C.for this reason 1 ITEMS
r4
Date: Plan check fee __
PLUMBING PERMIT ISSUING FEE$ , TOTAL 196.3
�
Signature CHECK 19C i`5
ElTOTAL FEE
Plan check applicant
� �
E FAMILY
HL NER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law IG1717-IJj ,j!�L
for the following reason(Section 7031.5, Business and Professions Address
Code):
1,
❑
45
I,as owner of the property,will do the work and the structure City Tel.No.
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 reg umbing, and hereby authorize
representatives o C y to nter upon the above-mentioned
property fort on pu a. _ SEE REVERSE FOR EXPLANATORY LANGUAGE
S na MIRSG Date
'DSPARTIIISNT 0�' I3IIILDINt 'AND AIIAPLICAZTON,FOR PS'RHZTy�•.
`\ilk e4 ;i,Vim . .,•C :
4MIRIP Iwo mum
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NATURE OP.INSTALLATiON DIiTRICT NO.- OR fJP�•• Nli I tRMfT No�aY •�
MP :v i •r•
}• 11[CftIV RL or
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APPLICANT FILL IN HE VILY OUTLINED PORTLON ONLY
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DEPARMENT 0t Z; IMINQ'AND'SAFg'TY ':�Ta�=�e�CAMONi•F0ft pSR�tIT;;0.
COUNTY OF LOS'ANOELS - .� ,. --n,'��`�w+
a, i ��PLUMBING
NATURE OF INSTALLATION'';, ®Ismiar No.: anouP �ZONRROUG" ON.
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APPLICANT FILL LY HEAVILY oUTIaINTD PORTION'ONLY 1 +•:�•
f s•`• 'NA As : .105 ..%-1
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