HomeMy Public PortalAbout5307 PAL MAL AVE_Plumbing__ WORKERS COMPE
havesnTIONcate of corse _' APPLICATION FOR PLUMBING PERMIT
1 hereby affnm that 1 have a certificate of consent oto self 7y A
insure or o certificate of Workers Compensation Insurance t CIE 917(REV 10"81)
or o certified copy thereof (Sec 3800 Lob C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished
❑ Certified copy is filed with the county budding tnspec FOR APPLICANT TO FILL IN(PRIM OR TYPE) BURDEN37(� / F}[,� /Q1
ADDRESS
I'm deportment NUMBER FIXTURE OR ITEM
LOCALITY -r Q,, c E ,T
Dote AppliSant / WATER CLOSET �� NEAREST -1 C
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB r c*=ST
COMPENSATION INSURANCE OWNER �► O/31 N S O a
(This section need not be completed If the work Involved by SHOWER
the perm"is for one hundred dollars($I00)or Ins ) MAIL MA ADDRESS S'A M
1 certify that in the performance of the work for which this If
permit is issued, I shall not employ any person in any manner SINK CITY TEL NO
so as to become subject to the Workers Compensation Lows DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT If, after making this Certificate of ADDRESS
Exemption, you should become subject to the Workers SWIMMING POOL RECEPTOR
Compemotton provisions of the Labor Code you must forth- LAWN SPRINKLER SYSTEM Cm TEL NO
with comply with such provisions or this permit shall be STATE
lX
deemed revoked WATER HEATER — LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION I DISTRICTBY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Profesuons Code and my license is in full force and effect 5 PER SYSTEM FINAL
DATE �r VALIDATION u
License Number 4c Class
FINAL QF
Contractor Dote BY P, U
❑ I am exempt under Sec d
N
B 8P C for this reason Plan check fee 2
Dote PLUMBING PERMIT ISSUING FEE$ d
Signature f;
TOTAL FEE � • • • : �
SINGLE FAMILY Plan check applicant h j • • (L 6 5
HOME OWNER BUILDER DECLARATION Name F
I hereby affirm that I am exempt from the Contractor s License Address c ^ ^
Law for the following reason (Section 70.31 S Business and ^� p 2 7—E 3
Professions Code) City Tel No
❑ 1 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 Nome
Lender's Andress
I certify that 1 have rood this applmahon and state that the Pilo
mcorrectformaeon is correct I agree to comply with all County
ordinances and State jaws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Igrature of Pommes Dote