HomeMy Public PortalAbout5538 PERSIMMON AVE_Plumbing__ (2) WORKERS'COMPENS TION DECLARATION APPLICATION FOR PLUMBING PERMIT
+s1uJt�e ffirm that I have acer'tificate of consent to self in- 76A66�A PW 4/87
iUre,ora '`tificate of Workers'Compensation.Insurance,ora CE 817(REV.8/86) I I I
certified i thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS LLLIII
Policy No. Company
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING rj a
❑ Certified copy is filed with the county building inspection ADDRESS �- �(' yjj'
NUMBER FIXTURE OR ITEM LOCALITY
department. @ FEE
Date Applicant WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST. of,
COMPENSATION INSURANCE SHOWER OWNER �,
(This section need not be completed if the work involved by MAIL r�
the permit is for one hundred dollars($100)or less.) I LAVATORY ADDRESS r �y
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CITY O TEL. NO.
as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR
Date--� ys Applicant V f k CLOTHES WASHER
�� f
NOTICE TO APPLICANT: If, after making ADDRESS'
this Certific a of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY /.2_. TEL. NO. ��t/
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE ��q L� LIC.
ed. WATER HEATER LICENSE NO. f� ' CLASS(✓J
LICENSED CONTRACTORS DECLARATION DIS7gdIEi-Nqr'�/ ROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS �
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL/ >.fect. DATION
t� t / DATE CLO
License Numb r / �f Lic. Class it
`I FION lJ
Contractor ' v J �/!-7` Date BY , / r
H
ZZ
1 am exempt under Sec. W
a
B.BP.C. for this reason ,
Plan check fee
te' PLUMBING PERMIT ISSUING FEE$
Signature �✓�
TOTAL FEE
SINGLE FAMILY ;20558A
HOME OWNER-BUILDER DECLARATION Plan check applicant # 0 0 0 0 o 5
1 hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and 1 5250
Professions Code): Address o a .52500:
I, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044, 0 8.3 0'i
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 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 representatty s of this County to enter upon the
above-mentione ert inspection purposes. i
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Per fee- Date