HomeMy Public PortalAbout5445 PARMERTON AVE_Plumbing__ AVQRKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT {�
' Wriereby oyf,rm that ve a certificateof onsent to self 76A667A u
insur_ rbrb6cale o Workers Comp sabon Insurance CE 817(REV 10/81)
or a cent Rcopy there (Sec-3000 C I COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No -am y
Certified ropy is
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING •r
Cert, ted cop fd !dl WMW
mspec ADDRESS S fbon depot ent NUMBER FIXTURE OR ITEM ® FEE ocAury Dote A WATER CLOSET NEAREST
CERTIFICATE OF E EMPTIO '' BATH TUB CROSS ST
COMPENSATION INSURANCE / SHOWER OWNER
(This stolon need not be completed If the work Involved by MAIL
the permit is for one hundred dollars ($100)or less ) J LAVATORY, ADDRESS
I certify that in the performance of the work for which this
permit is issued I shall not employ any person,n any manner SINK CITY TEL NO
so as to become subject to the Workers Comp5trisation Lows DISHWASHER _
CONTRACTOR r ;7
Date —/a A7 4 ApplicaCLOTHES WASHER
ADDRESS JOYV
NOTICE TO APPLICANT If after making t
Exemption you should become subject the.Workers SWIMMING POOL RECEPTOR Q
Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM CITY �� 4byoTEL NO 7
with comply with such provisions or this permit shall be STATE I UC
deemed revoked 1 ! LICENSE N
WATER HEATER O CLASS
LICENSED CONTRACTORS DECLARATION Oji �� SSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS G✓-.
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is,n full force and effect 5 PER SYSTEM FDIAN EL ,'- VALIDATION
License NumberyfZ (�9L,c ClassG_3(a o
Conrra<to4: 'L✓�A &IPfete
/6 BN U
❑ 0
I am exempt under Sec
B 8P C for this reason a
�� Plan check fee PiloDaj to / PLUMBING PERMIT ISSUING FEE E Z
Signet .i/u's((
TOTAL FEE
Plan check applicant '
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Noma
I hereby affirm that I am exempt from the Contractor s License Address
Law for the following reason (Section 7031 5 Business and
Professions Cade) City Tel No
❑ 1 as owner of the property will do the work and the ,
structure is not intended or offered for sole (Section , 2 5 4 1 2 A
7644 Business and Professions Code)
CONSTRUCTION LENDING AGENCY # • is • • is 5
' I hereby nffirm that there is a construction lending agency for
the performance of the work for which this permit is issued ,I • • 36 50
(Sec 3097 Civ C ) -
, • • • 34.50
Lender s Nome
09, 10y86
Lender s Address ,
' I certify that I have read this application and state that the ►
above information ,s correct I agree to comply with all County -
ordinances and State lows regulating Plumbing and hereby
authorize representatives of this County to enter upon the
above mentio a property (or inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
erm rttee . Dote '