HomeMy Public PortalAbout5929 ROWLAND AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby,&firm that I have a certificate of consent to self 78AS87A
, insure, or certificate of Workers'Compensation I iranCO, CE 817(REV.8/88)
If�Pl'
c ied copy thereof(See. 3800, C. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
No. Company
Certified copy is hereby furnished. BUILDING ;
13FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
WATER CLOSET r'L _7
Date Appli;ant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB � 00 CROSS ST. 000 L
COMPENSATION INSURANCE SHOWER 61 Q/J OWNER� - AIALAK J U161
(This section need not bo completed if the work Involved by �/ MAIL n
the pormit Is for one hundred dollars($100)or less.) 3 LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL.NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR sJ(mll?Ve-l7QVJ
Date Applicant CLOTHES WASHER ADDRESS MilkV (,�W(:L Z
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY I&A
TEL. NO. �t7�
with comply with such provisions or this permit shall be STATE i LIC:
deemed revoked. ( WATER HEATERLICENSE NO. WSJ CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9
GAS SYSTEM OUTLETS ((//JJ��
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER g
and Professions Code,and m license is in full force and effect. 5 PER SYSTEM
Y FINAL
_ VA DATION
License Number Lic. Class QE
FINO
Contractoi � `U"'� Date 8&/c?
BY
❑ I am exempt under Sec.
B.BP.C. for this reason Date: Plan check fee ® 2
PLUMBING PERMIT ISSUING FEE$ g 7 7 5 4 A
Signature
TOTAL FEE # 0 0 0 0 0 5
Plan check applicant 1 - 7650
SINGLE FAMILY o - 76506
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address o a 2 6 a.8 7
Low for•the following reason (Section 7031.5, Business and
Professions Code): 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 Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all Count'
ordinances and State lows regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
abo -mentioned roperfy for Inspection pur oses.
O SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature)(J#&rmIttee Date