HomeMy Public PortalAbout5344 PERSIMMON AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT 0,11
I hereby affirm that-1 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 thereo (Sec. 3800, La C COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company u
4
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE), BUILDING
Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY f
LVOXDate Appli4 WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTIONFR ORKERS' BATHTUB CROSS ST. r' Pitt
COMPENSATION INS NCE SHOWER ,1 OWNER Z�
(This section need not be completed If the work Involved by IJ MAIL
the permit Is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL.NO. 3g`
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Datis —Applicant CLOTHES WASHER ADDRESS
NOTICE TO. APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- 4ST2A
ITY TEL. S94-71
with comply with such provisions or this permit shall be r.LAWN SPRINKLER SYSTEM E LIC.
deemed revoked. WATER HEATER NSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DIMICT NW CESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS `/S 0
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER `J (�
and Professions Code,and my license is in fu)I force and effect. 5 PER SYSTEM FINAL
DATE --+5 V DATION
00
License Number d Lic. Class . Q
FI � � C
XContractor Date B
Q
❑ 1 am exempt under Sec. C
B.&P.C. for this reason n
Plan check fee
Date: tl
PLUMBING PERMIT ISSUING FEE$ s 'e
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION i Name ;2 6 3 315 A
I hereby affirm that I.am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and # 00 0 0 0 5
Professions Code): City Tel. No. i1 0 0 3 11,5 0
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section ® 0 0
7044, Business and Professions Code). 1 ;�
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 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
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::bFntione property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE,
nature. er ee Date