HomeMy Public PortalAbout5451 PARMERTON AVE_Plumbing__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
Insure or a certificate of Workers Compensation Insurance CE 817(REV 10/81)
or a certified copy tF eof (Sec 3800, L C /
P❑oltcy No�Q/ j CompanyCOUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished /,
ElCertifiedcopy is filed with the county budding inspec FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
SA OC� To
eon department NUMBER FIXTURE OR ITEM FEE r 1'
j LOCALITY Te T
Date Apphgant WATER CLOSET NEAREST _
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CRO55 57 tiJ S
COMPENSATION INSURANCE I
SHOWER OWNER 1J C r1 MAIL ��(/
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($180)or less ) LAVATORY ADDRESS �yS [ \1Z^1 '
I certify that in the performance of the work for which this
permit is Issued I shall not employ any person in any manner SINK CITY C , TEL NO
so as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR Q Z � ` a fl
Date Applicant - CLOTHES WASHER
NOTICE TO APPLICANT If, after making this Certificate of ADDRESS '2� Z Su L T•
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth- CITY TEL NO Z '97-5-14 ] ]
with comply with such provisions or this permit SPRINKLER SYSTEM permit shall be STATE / LIC �FR�
deemed revoked WATER HEATER LICENSE NO rc,O C3 Z 7 C f/' —
If J
LICENSED CONTRACTORS DECLARATION DISTRICT NO SSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER a
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL r VALIDATION O
DATE III
O� U
License Number , X02 7 Lc Class p.
7 / FINAL O
Contractor � BY
❑ W
I am exempt under Sac N
B 8P C for this reason Z
Plan check fee
Data PLUMBING PERMIT ISSUING FEE$ (�
Signature �
TOTAL FEE 5d
Plan check applicant •�
SINGLE FAMILY `� L N �" :92080A
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor s License _ # • • • •s• 5
Law for the following reason (Section 7031 5 Business and Address 2- Z u L N t
Professions Code) City C Tel No 2 5 4 2'- e 4 Q 5 0
❑ I as owner of the property will do the work and the • s e 4 G•5 0 15
structure is not intended or offered for sole (Section ,
0
7044 Business and Professions Code) i Cal B—8 3
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is o 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
oboe -mentioned prosy inspection nspection purposes
for
NsY/r/ SEE REVERSE FOR EXPLANATORY LANGUAGE
S " 19-e�f3
—Signature of Permittee Date