HomeMy Public PortalAbout5804 PRIMROSE AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
Lt hereby affirm that I have a certificate of consent to self I 20-0026 DPW 6/87 i
Insure, or a certificate of Workers'Compensation Insurance, 76A667A ;
otr a certified copy thereof(Sec. 3800, Lab. C.) ® COUNTY 01: LOS ANGELES I DEPT.OF PUBLIC WORKS L 1
i" f s7k
Policy Nof���'!R1/It:�Company r
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) �
91�erfified copy is filed with the county building inspec- I ADDRESS Q R �m 1(e,(SSCJ
tion department. NUMBER FIXTURE OR ITEM _
t I @ FEE LOCALITY
ll WATER.CLOSET
Date C/' Appli4ant / //-C �� J74 IEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CROSS SL O;fL� p-el
COMPENSATION INSURANCE ( SHOWER OWNER
(This section need not be completed If the work Involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS j5eM E_-
I certify that in the performance of the work for which this. I t
permit is issued,I shall not employ any person in shy manner SINK CITY 'T TEL. NO. y tJ
so as to become subject to the Workers'Compensation Laws. DISHWASHER I
CONTRACTOR
Date Applicant CLOTHES WASHER p
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS 0 w
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY ���� TEL. NO.
P P Y LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER 21 LICENSE NO. S L{L( &W
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I herebyaffirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS r j
(commncing with Section 7000)of Diviion 3 of the Business i OUTLETS OVER `��� y
and Professions Code,and my license Is in full force and effect. 5 PER SYSTEM FINALr°�/gyp ...Q� VALIDATION II
DATE C
License Nut`mberS�S rq� Lic. Class 1177-201 -3Co !j� C�
l/f�A 2 6t SLA �l 3 i BY FINAL(� //a It
C
Contractor IYYI �4 Date r- gg�--
❑ I am exempt under Sec. I C:
B.AP.C. for this reason
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE'$ /
Signature TOTAL FEE v� 5
Plan check applicant
'SINGLE FAMILY `
HOME OWNER-BUILDER DECLARATION Name ��
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): City Tel. No. ( 1�7
❑ I, as owner of the property, will do the work and the i ITEVII +
structure is not intended or offered for sale (Section ® a
7044, Business and Professions Code). TOTAL i AL 2 0 . 51011
CONSTRUCTION LENDING AGENCY �""(` I '
I hereby affirm that there is a construction lending agency for i CHECK ■51.
the performance of the work for'which this permit is issued (;HOSE aLil�
(Sec. 3097, Civ. C.).
Lender's Name r, 5.124'81
Lender's Address. 2'+
I certify that I have read this application and state that the ® #'" S �` 83: �
above information is.correct. I agree to comply with all County i
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the i
above-mertione pro ty f ins' ction purposes.
_ SEE REVERSE FOR EXPLANATORY LANGUAGE
S' nature of PermitDate I t
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