HomeMy Public PortalAbout5033 SANTA ANITA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION ., . a ' APPLICATION FOR.PLUMBING PERMIT
I hereby affirm that1 have 4certifi6e 9f,co to self 20 p026 DPW 6/67
insure, ora certificate of Workers'Compens�'R'Irisurbriee, 7dA667A `.
" mr,a certified-copy thereof(Sec. 3800, Lab. C.),, COUNTY OF LOS ANGELES I DEPT.OF PUBLIC WORKS
acy No. Company
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE)❑ ADDRESS Certified copy is filed with the county building In NUMBER FIXTURE OR ITEM FEE I
tion department: /h' LOCALITY
Date Appllgant u WATER CLOSET NEAREST �� S
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER i OWNER .p \
(This section need not be completed if the work Involved by ®o MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS �. CIOLt
I certify that in the performance of the work for which this n
10
permit is issued,1 shall not employ any person in any manner / SINK V CITY TEL. NO.
so as fo become subject to the Workers'Compensation laws. , DISHWASHER
I 17 5 Q CONTRALTO M)I "Date Applicant CLOTHEj�S WASHER v ADDRES
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY TEL.NO.
Compensation provisions of the Labor Code, you must forth- —��
LAWN SPRINKLER SYSTEM
with, comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER 7 15 j} LICENSE NO.��� CLASS
LICENSED CONTRACTORS DECLARATION v DISTRICINO. ROCESSED
I hereby affirm that I am licensed under provisions of Chapter 9 / GAS SYSTEM OUTLETS .
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER'
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM. FINAL ] V DATION
License Number Lic. Class —
FINAL
IM
Contractor Date I. I BY O
❑ I am exempt under Sec. I V
BAP.C. for this reason
Plan check fee I ►
Date: PLUMBING PERMIT ISSUING FEE$ Q
Signature
TOTAL FEE
SINGLE FAMILY
Plan check applicant j
l
HOME OWNER-BUILDER DECLARATION Name ACCT.V
1 hereby affirm that I am.exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address j 3,+07 95.50
.
Professions Code): 1, City Tel. No. 1 ITEMS
❑ I, as owner of the property, will do the work and the TOTAL. ,
structure is not intended or offered for sale (Section
7044, Business and Professions Code). ,
CONSTRUCTION LENDING AGENCY CHECK 95.50
s
I hereby affirm that there is a construction lending agency for CHANGE .011
the performance of the work for which this permit is issued
(Sec. 3097,Civ. C.).
Lender's Name I 00130-0001' 5/30/90
Lender's Address - 0999 1 Ail 9 o Sz
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 i
authorize representatives of this County to enter upon the
above-me ned property for inspection purposes. !
SEE REVERSE FOR EXPLANATORY LANGUAGE
�I
ignature o ermittee Date ;