HomeMy Public PortalAbout5654 PAL MAL AVE_Plumbing__ WORKERS CI have ATIONDECLARconse APPLICATION FOR PLUMBING PERMIT
ATION
I hereby affirm that I have a certificate of consent to self 20 0026 DPW 8/87
insure or o certificate of Workers Compensation Insurance 76A667A
or a certified copy thereof (Sec 3800, Lab C ) COUNTY OFIOS 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 budding lospec ADDRESS L
tion department' NUMBER FIXTURE OR ITEM ® FEE LOCALITY
Dote Apphtant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
COMPENSATION INSURANCESHOWER OWNER
(This section need not be completed If the work Involved by
MAILthe permit is for one hundred dollars (1100)or less ) LAVATORY T 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 CITYllf
TEL NO O
so as to become subject to the Workers Compensation Laws DISHWASHER CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS — -
NOTICE TO APPLICANT If, after making this Certificate of r
Exemption you should become subject to the-Workers SWIMMING POOL RECEPTOR r
Compensation provisions of the labor Code, you must forth- CIN TEL NO
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE UC t
deemed revoked WATER HEATER i LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT PROCESSED 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 LCttiL
and Professions Code and my license is in full force and effect 5 PER SYSTEM FFDIANL _Z VALIDATION 0s
License Number Lic ClassU
� - FINAL �
Contractor Date , By O
❑ 0 I am exempt under $ec W
B 8P C for this reason W
Plan check fee Z
Date
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
' Plan check applicant
SINGLE FAMILY
i
a
HOME OWNER BUILDER DECLARATION Name11K)7XA
I hereby affirm that I am exempt from the Contractors License
Law for the following reason (Section 7031 5, Business and Address
Pyofessions Code) City i Tel No _
I as owner of the property will do the work'and the , 01 r�� 9 - 30
structure is not intended or offered for sale (Section CHEC 1• 31T D
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY I.HeP 1 ,1111
I hereby nffvm that there iso construction lending agency for
the performance of the work for which this permit is issued
(Sec 3097 Civ C )
fl;Iqq—npsa i 1!'4/9_
Lenders Name 1_Ilb 1 All 111:-710
Lender s Address
I certify that t have read this application and slate that the
above information is correct I agree to comply with all County
ordinances and State laws regulating Plumbing and hereby
aulhonz reprArmotives of this County to enter upon the
above �on property for inspection pur ores
SSSEE REVERSE FOR EXPLANATORY LANGUAGE
5i6not6re 9 Permittee / v ate