HomeMy Public PortalAbout5502 PARMERTON AVE_Plumbing__ W(JRKERS COMPENSATION DECLARATION ' -APPLICATION FOR PLUMBING PERMIT
• 76A667 DPW 1/90
I hereby, affirm that I have a certificate of consent t n self in- 76A667A +-
sure or a copy
thereof Workers'Compensation Insurance,or a
certified copy thereof (Sec 3800 Lab C ) � T � �
Pohcy No Company COUNTY OF LOS ANGELES DEPLLOF PUBLIC WORKS
❑ Certified copy is hereby furnished
Certified copy m filed with the county budFOR APPLICANT TO FILL IN(PRIM OR TYPE) BUILDING
dding inspection ADDRESS 5502 &_rrm e r toyl Y/ V
department NUMBER FIXTURE OR ITEM @ //FEE LOCALITY
Date Applicant WATER CLOSET(TOILET) /(p NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB 6 O CROSS ST Pal n e s
COMPENSATION INSURANCE SHOWER OWNER �"e-�'� Note— `.�
(This stolon need not be completed if the work involved by q
the permit is for one hundred dollars ($100)or less) LAVATORY ADDRESS SSS Z P4 rrn el^ton /4 V 2
MAIL
1 certify that in the performance of the work for which this per- SINK -
mu is issued I shall not employ any person to any manner so CITY TBYYI !e C I `1� TEL NO ag9-s670
as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR owner
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT If after making Certificate ADDRESS
of Ex-
you should became subject to thea
Workeri Co Compen- SWIMMING POOL RECEPTOR CITY TEL NO
sanon provisions of the Labor Code, you must foithwah comp- LAWN SPRINKLER SYSTEMS
Iy with such provisions or this permit shall be deemed revok- STATE UC
ed WATER HEATER _ LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS �O G
9(commencing with Section 70DO)of Division 3 of the Business OUTLETS OVER O
and Professions Code and my license is to full force and of 5 PER SYSTEM FINAL VALIDATION
fact HOSE BIB DATE y
L¢ense Number L¢ Class C
FINAL U
Contractor Date - BY im a 75},/5(]0
F-1Y
I am exempt under Sec ,/ H
n W
B 8P c for this reason Plan check fee , �,r(L T17 pryµ 1 TE S � h 'A
[QJ'.I��j9.�7/�t 1'
Date PLUMBING PERMIT ISSUING FEE$ _
Signature O 000 -��1 771J:Jy'
Q
SINGLE FAMILY TOTAL FEE ,�j 1312 1 AM ^M
'
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor s License Name -
Law for the following reason (Section 7031 5 Business and -
1Pro'fessions Code) Address
IOL I as owner of the property will do the work and the City Tel No
structure is not intended or offered for sole(Section 7064
Business and Professions Code) Poo.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 '- -
Lenders Address
I certify that I have read this application and state that the ,
above information is correct I agree to comply with oil County
ordinances and State jaws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
above mentioned prop ty for inspection purposes
nr — 91,5-91,5- SEE REVERSE FOR EXPLANATORY LANGUAGE
a ure of Permittee Date