HomeMy Public PortalAbout5741 ROWLAND AVE_Plumbing__ - � RKEg-S&COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
�.hereby,affirm that I have a certificate of consent to self 76A667A
p1nsure,46r'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
Policy No. Company
Certified copy is hereby furnished. BUILDING
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS �7
Certified copy is filed with the county building inspec-'
tion department. NUMBER FIXTURE OR ITEM rQ FEE n�
LOCALITY L—
Date Appliqant WATER CLOSET .� Da NEAREST r`
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB Q CROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be completed If the work Involved by SHOWER ,f KZbl
the permit is for one hundred dollars $100 or less. MAIL
P ( I ) "3 LAVATORY 6 ADDRESS
I certify that in the performance of the work for which this'
permit is issued, I shall not employ y person in any manner SINK CITY TEL.NO.
so as to become subject to the W ern'Compensat'on Laws. DISHWASHER
,� �—�� CONTRACTOR
Date Applican CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, t r making this Certifi of
Exemption, you should b c me subject to the orkers' SWIMMING POOL RECEPTOR
Compensation provisions a Labor Code, you must forth- CITY TEL. NO.
LAWN SPRINKLER SYSTEM
with comply with such p ovisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT O. tt O ED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 4 �t
(commencing with Section 7000)of Division 3 of the Business s OUTLETS OVER t)
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALID TION
DATE p
License Number Lic. Class C
FIN C
Contractor Date BY e
❑ F
I am exempt under Sec.•
B.&.P.C. for this reason C® C
Plan check fee
Date: u
PLUMBING PERMIT ISSUING FEE$ C
Signature ;94959A
TOTAL FEE
SINGLE FAMILY Plan check applicant # 0 0 0 0 0 5
HOME OWNER-BUILDER DECLARATION Name I ° a 5 a 5 0
1 hereby affirm that I am exempt from the Contractor's License Address o 0 0 5 a 5 0 Ft
Law for the following reason (Section 7031.5, Business and
Profen ' Code): City Tel. No. 07.03
—86
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 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
a orize representatives of this County to enter upon the
ove-mentioned properA for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date