HomeMy Public PortalAbout5945 ROWLAND AVE_Plumbing__ WORKERS'COMPENSATION DECLAR.110 � APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of con;nn+ to self ;76A667A
insure, or a certificate of Workers'Comper.,ation 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
E] FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS .�
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM W. FEE LOCALITY
Date Applicant WATER CLOSET
NEAREST ^� �
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST *� J
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by ISHOWER
the permit Is for one hundred dollars($100)or less.) LAVATORY MAIL
ADDRESS 4,41cl id-'t ,at
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any mann r., SINK CITY ," - i 7.i .' TEL. NO(,y q �Z
so as to become subject to the Workers'Compennssatio L DISHWASHER CONTRACTOR �J � x
1
92
Date-U cJ'�'�)—Applicant %1� v •� �_- CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, afte aking this Ce iflcate of
Exemption,Exem you should become subject to th Workers' SWIMMING POOL RECEPTOR CITY v
p I � ,� TEL.NO.
Compensation provisions of the Labor Code, you must forth- ( J
P p y LAWN SPRINKLER SYSTEM �
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CIAM
LICENSED CONTRACTORS DECLARATION DISTRICT PROCESS BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER '
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDAT
0 `« Slb-& DATE
License Number Lic. Class o Gi,
FINA
Contractor Date BY /%/7Zr-
❑ 1 am exempt under Sec. /
CORI
B.&P.C. for this reason Date: Plan check fee 01111,PLUMBING PERMIT ISSUING FEE$ &_10
Signature
TOTAL FEE r G i $ I A
Plan check applicant 0 0 0 0 0 5
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name I o o 1 6 5 0
1 hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and o o o i 6506
ro essions Code): City Tel. No.
bn3 85
Pq 1, as owner of the property, will do the work and the
O —
structure is not intended or offered for sale (Section pop7044, 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 representatives oft .A County to enter upon the
above-mentioned pro t inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nature of Permi a Date