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HomeMy Public PortalAbout5233 PAL MAL AVE_Plumbing__ (WORKERS'COMPENSATION DECLARATION APPLICATION FOR .PLUMBING PERMIT r I � •a�f'irm that+l have a certificate of consent to self 76A667A u e, of a certificate.of Workers'Compensation Insurance, CE 817(REV. 10/81) i ora.certified:cothereof(Sec. 3800; Lab. C..) COUNTY;OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with th..e county building inspec ADDRESS - NUMBER. FIXTURE 09 ITEM ®. FEE Q tion department. LOCALITY WATER CLOSET e Date Appli4ant QQ NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. Pire COMPENSATION INSURANCE OWNER `` (This section need not be completed if the work involved by r SHOWER: ; a� d O�� MAIL the permit is for one hundred dollars($100)or less.) LAVATORY ® ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY `p. TEL.NO. i so as to-become subject to the Workers'Compensation Laws. DISHWASHER ,J CONTRACTOR Date 10 44,f /�AppliOnt abi�. +.Qirnd CLOTHES WASHER Q© ADDRESS ryl NOTICE TO APPLICANT: If, after making this Certificate of Q Exemption, you should becomesubject to the Workers' SWIMMING POOL RECEPTOR 'Compensation provisions of the.Labor Code, you must forth- CITY TEL.NO. LAWN SPRINKLER SYSTEM with comply with such. provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS. LICENSED.CONTRACTORS DECLARATION DISTRICT NO. OCESSED BY I hereby off irm that I am licensed under.provisions of Chapter 9 GAS SYSTEM OUTLETS 00 (commencing with Section'7000)of Division 3 of the BusinessoUTLETSOVER IL and Profession's Code,and my license is in full force and effect. 5 PER SYSTEM FINALVALID ON V DATE License Number Lic..Class _ 6 FINAf O ContractorDate BYW � ❑ 181 I am.exempt under Sec. JIL B,BP,C. for this reason z Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ 10 Signature &D 9 Q$(j,Q A TOTAL FEE Plan check applicant 0 0 0 0 0 5 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION. Name V- 4650 ' I hereby affirm that I am exempt from the Contractor's License Address o 0046506 Law for the following reason (Section 7031.5, Business and Professions Code): I City Tel. No, 1 G09-84 ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 1101.7044, 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 property for inspection purposes. �) SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORVRSCOMPENSATION DECLARATION APPLICATION. FOR PLUMBING PERMIT I her ,fir a}irmf that?`have a certificate of consent to:self 76A.�7A insure, oris certificate of Workers'Compensation insurance, CE 817(REV. •10/81') a or a certified copy thereof(Sec.3800,.Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby•furn!shed. BUILDING s— Certified ropy is.filed with the county-building inspec- FOR APPLICANT TO FILL IN(PRINT OR TYPE) -ADDRESS � 3'. tion department. NUMBER FIXTURE-OR ITEM @ FEE LOCALITY e Date Appli4ant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. r COMPENSATION INSURANCE SHOWER. OWNER + (This-section need not be completed if the work'tnvolved by MAIL. the permit is for one hundred dollars'($100)or less.) LAVATORY Pal Mea ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL.NOW to as-to,become subject to.the Workers'Compensation Laws. DISHWASHER CONTRACTOR Date Applicant. r CLOTHES WASHER ADDRESS r NOTICE: TO APPLICANT- If, after making this Certificate, of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY TEL.NO. Compensation provisions of the-Labor Code, you must forth- LAWN SPRINKLER.SYSTEM With comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCESSED BY I.hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS .(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and.my license is in full force and effect. 5 PER SYSTEM FINAL DATE VALID ION U License Number Lic. Class cc FINAL O Contractor Date BY U '❑ I am.exempt under Sec. X 1 3 3.9 A y B.&P..C. for this reason ► Plan check fee # 0 o�0 0 0 5 Date: PLWM81NG PERMIT ISSUING FEE$ Signature —::A 6 l o -1650 TOTAL FEE Plan check applicant ° ° 0 1 6 5 0 53 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name O 1. 14-85 1 hereby affirm'that I am exempt from the Contractor's License Address Law foi the following reason (Section 7031.5, Business and •Prgfessions Code): City Tel. No. YYJJ�11 I, as owner of the property, will do the work and the 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE A: yw4-pj_ 1-114-85 ignature of Permittee Date