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HomeMy Public PortalAbout5313 PERSIMMON AVE_Plumbing__ WORKERS'COMPENSATIQIL DECLARATION j 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 thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY I Policy No. Company Certified copy is hereby furnished. I BUILDINGj� ^ ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRES5:3 1,3 ) c�SI jw W� V Certified copy is filed with the county building inspec- tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY C' 4/ r 1 Date Appligant WATER CLOSET © NEAREST r CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB A—CROSS ST. COMPENSATION INSURANCE s1 OWNER,,_J 1� j ' Lo E;(„C_ (This section need not be completed if the work involved by SHOWER V the permit is For one hundred t)allars(S tO s.) a_ LAVATORY DDRESS ��1<�4L_ w. C�(J I certify that in the performance of the w rk for w ich this SINK CITYr TEL.NO. / permit is issued, I shall not employ any p rs'on in an manne� (. �(,- � ? 3 7 so as to become subject to t(he Workers' ompensa on L ws. ^r DISHWASHER CONTRACTOR Date L / pplica CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, afte m Ing this Cer ifica a of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. P 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 616 1 911. and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALID ATI 0 DATE License Number Lic. Class FINAL K 0 Contractor Date BY AfV ❑ I am exempt under Sec, 0.y' B.BP.C. for this reason ► 2• Plan check fee a Date: 08$,bA PLUMBING PERMIT ISSUING FEE$ Signature 0 0 0 0 0 5 TOTAL FEE Plan check applicant 1ooaQ50 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name 0 o c 4 Q 5 V I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and Professions Code): I City Tel. No. ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section , 7044, Business and Professions Code). 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 Lender's ess AzQ at I ave read this application and state that the , ma' correct. I agree to comply with all County dn Stat laws regulating Plumbing, and hereby ep sen fives of this County to enter upon the } ' ned roperty for i spection purposes. ' SEE REVERSE FOR EXPLANATORY LANGUAGE —&f Per ttee Date