HomeMy Public PortalAbout5551 PARMERTON AVE_Plumbing_11/18/1992_bathroom fixtures and gas system WORK COMPENSATION DECLARATION 20 667 DPW 9189 APPLICATION FOR PLUMBING PERMIT
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I hereby affirm that I havehave a certificate of consent to self insure 70A0026
or a certificate of Worker s Compensation Insurance or a certified
copy thereof(Sec 3800 Lab C)
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV
P❑ohcy No, Company _
Cenrtied copy is hereby furnished
Icy FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
L7 Candied copy is filed with the county bwlding inspection ADDRESS 5 Q� V.-,AA
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tlepe�nlm�en/t�r� i NUMBER FIXTURE OR REM ® FEE�1I l "1 L LOCALITY Tr
Dale Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS CROSS ST
COMPENSATION INSURANCE BATHTUB ] t '
ASSESSOR Q
(Thu section need not be completed If the work involved by the SHOWER 'f300K B PAGE PARRL'
permit Is for one hundred dollars($100)or leas) OWNER p,� �H �*
I certify that in the performance of the work for which this permit MAIL
LAVATORY
is issued I shall not employ any person in any manner so as to S4NK ADDRESS - —
become subject to the Workers Compensation Laws
DISWASHER CITY TEL NO
Data Applicant CLOTHES WASHER CONTRACTOR J �Q
NOTICE TO APPLICANT It after making this Certificate of
'Exemption you should become subject to the Workers Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code you must forthwith comply with such 1;LA1 S VvlO�\
provisions or this permit shall be deemed revoked - , LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION Cm ` C TEL NO }
I hereby affirm that I am hcensed under provisions of Chapter 9 WATER HEATER STATEa.� l((r a
(commencing with Section 7000) of Division 3 0l me Business and GAS SYSTEM ETS CENSE NO `�I 0 `e CUSS
Professions Cade and my license is in full force and effect
OUTLETS OVER DISTRICT NO PROCESSED BY
5 PER SYSTEM
^yS Q
License Number Lc Close 1 U
ATE VALIDATION LLI
D —L
Contractor Date vV y
❑ I am exempt under Sec FINAL ZBy
B 8P C for this reason
Date000.
fee $
' Plan-check�_
&gnat �e a: PLUMBING PERMIT ISSUING FEES Lf ACCTei _
✓ TOTAL FEE17
T ()8.40
SINGLE FAMILY Plan check apphcanl S 1 TTCk,I.
HOME OWNER BUILDER DECLARATION Name TOTAL i tCJIJ6� - �
I hereby affirm that I am exempt from the Contractor a License Law _ i '
for the following reason (Section 7031 5 Business and Professions Address 11 \wi yv.\Q.rT DECK _ (�,'+(I
Code) y .Cr 4�1 2,Z 4.` t tt.�n _ 68 L
❑ Crt _ Tel No ., �f1t911L . ]
I as owner of the property will do the work and the structure fV9riL
is not intended or offered for sale (Section 7044 Business
and Pro/ Code)
CONST , yyyy—WQ1 lvl�i� �
CONSTRUCTION LENDING AGENCY �CL C[
I hereby affirm that there is a construction lending agency for the _ 6JOT 1 -Ail 18:54performance of the work for which this permit is issued (Sec d3097 - '
Civ C)
I
fit ender a Name _ \
_ _ o
Lender a 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 above mentioned
p y for ins ion purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
9 ,
S gnature of Permittee Date