HomeMy Public PortalAbout5532 PARMERTON AVE_Plumbing_1/2/1990_bathroom fixtures WORKERS'COMPENSATION DECLARATION - -`� — APPLIC_ ATION FOR PLUMBING PERMIT '
20-0026 DPW 4/87
Iher?by`off rnthot I hove a cerbf,catee`,of consent to self'A ,76A667A r r
3 sure,oria certificate of Workers Compen otton'lfisuronce'or a• CE 817(REV 8/86)
'cert, ied copy thereof (Sec 3800 Lab C ) { s
'y No ' , . ' , . COUNTY OF LOS,ANGELES
PolicDEPT OF PUBLIC WORKS' >
Company + - „ _' i ? ,
'Ceinfied copy is'hareby furnished �' �' _ BUILDING ��••++)) �a`n� •4 r` '
I f-0R APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS �J...)Z' l#T '• ^
Ceithed copy is filed wtth the county building'impech on
rL `department r y - r - f v. , - NUMBER FIXTURE OR ITEM @• -FEE , LOCALITY (�/�/y. � rr `
c - b x .. WATER CLOSET(TOILET) - 1 - ' r '
Date +' Apphcont i _ r ` t i NEAREST
S- CROSSST N •`x
CERTIFICATE OF EXEMPTION FROM WORKERS', r6ATH TUB
I COMPENSATION((NSURANCE '1, / x ` OWNER
SHOWER , ` _
`I (Jlns:Isvi.;need not be completed If the'Work involved by MAIL '
t"prmlt is for one hundred dollars,($100)or 16is')3 t 'LAVATORY - ADDRESS
I`cerhfy'thot in the performance of'the work for which this per + -
mrt is issued I shall not employ any person in any manner so - SINK 'CITY ° '" TEL NO
as to become iublect to the Workers Compensation Laws , ` e
. ; , DISHWASHER v CONTRACTOR
z •` - LlNQ4� ,
Dote ,Applicant CLOTHES WASHER' ,1 -
p NOTICE TO'APPLICANT If after making this Cerhhcate of Ex _ - ADDRESS a,•,I}M'1p r „ „
emphon you should become'subject to the Workers Compen {' - SWIMMING POOL RECEPTOR �{ CITY + t' TEL NO'7 Y `
sation provisions of the Labor Code'you must forthwith camp d zy . LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok STATE + UC
ed i - ' t . - , ' N • - , d °_^ WATER HEATER' ' LICENSE NO CLASS
71 `LICENSED CONTRACTORS DECLARATION y - DISTRICT NO Q SSED BY
I hereby ofhrm that I am hcerised under provisions of Chapter _ eF GAS SYSTEM ,• OUTLETS ` U�v
9(commencing with Section 7000)of Division 3 of the Business ,' Y OUTLETS OVER - p _
and Professions Code and my license is in full force and of 5 PER SYSTEM - FINAL ' .I
' feet ` _ _ v _ DATE �� _� VALIDATIO , O
License Number '1 - Lice ClassF ' -, , _ U
'Y FINAL i IC
,Contractor - Datey _ + BY - O
U
0 I am exemptsunder Sec! T }_ f " A, ^ x, r W
N
B 8P C for this reason _ Plan Check fee ' '^ , - - , 2
Date• PLUMBING PERMIT ISSUING FEE$
, . � � _ • TOTAL FEE O a r +
SINGLE FAMILY •p
v
Y HOME OWNER BUILDER,DECLARATION Pion check applicant _ _ - - `
I hereby affirm that I am exempt from the Contractor s License Name ri f
r Law`"for the following reason (Section 7031 5 'Business dnd w " -T -. �,:a 5- „, .... .+,�'
Professions Code) yx ' o� Address ,,,. y •ry „ _ ' u "
fhl I, as owner of ihe'`property "will-do the work and'the w y „ :-tn x �+� ACCT.3
' Cit '` Tal No• -
siructuia is not intended or offered for sale(Section 7044 , u - 3307 - --,-- 50.5{1
Business and Professions Code) 2 e r r' 1 IT
y, i !' CONSTRUCTION LENDING AGENCY - r +TOTAL t` � �
I hereby affirm that Iheretis ci construction lendingogency for ( Y ` - �'' ' - - \ s- r
the performance of the work for which this permit is issued •' C1n •, 50.ed�s
(Sec 3097 Cry,C`) t - x _ I - �K T
`r� CHANGE ' .Oc(
.Lenders Nome
„Lenders Address f� i Y '� - . 130013-0001 ' 11 2/9 t
I certify'that I have read his application and state hal he
above mformohon is correct I agree to comply with all County 't,.� W'� `, , v r 7915 - 1 AM .
ordinances and State IoWs regulating Plumbing and hereby
authorize representatives of-this County to enter upon the
abev'e mention d property for inspection purposes - _
' r�' - SEE,REVERSE FOR EXPLANATORY LANGUAGE `
• Sign ure of Perm Rtee v"` Doe �s-w- - ~ i