HomeMy Public PortalAbout5543 1/2 SANTA ANITA AVE_Plumbing__ WORKERS'COMPENS4TION DECLARATION r,
APPLICATION FOR,PLUMBING PERMIT
I h;reby,off irm that I have a certificate of consent to self' I 76A667A •
insureL orla•'cerf'if!tote of Workers'Compensation Insurance, 1 CE 817(REV. 10:vX$
or a certifieM7pthereof(Sec. 3 Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
rPolicy No. Compan `�%
❑ Certified copy is hereby furnishe BUILDING�
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BU
Certified copy is filed with the county b ng 1 spec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY ) �.
c
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB OZ CROSS ST.
COMPENSATION INSURANCE OWNER (ri co
(This section need not be completed if the work Involved by SHOWER �� o
the permit Is for one hundred dollars($100)or less.) LAVATORY MAIL f � ,ry
ADDRESS,CX/ _`7 a t '
I certify that in the performance of the work for which this j
permit is issued, I shall not employ any person in any manner - SINK CITY ��, ' TEL. NO.��5
so as to become subject to the Workers'Compensation Laws. 42
DISHWASHER �' ]�}�
L
CONTRACTOR 7 0' laM2 ad4a—
Date Applicant / CLOTHES WASHER �/� '
NOTICE TO APPLICANT: If, after making this Certificate of ADDRES ' r?a t •i A
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY TEL. N
Compensation provisions of the Labor Code, you must forth-
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. / WATER HEATER it
N 7 CLASS G/ s
LICENSED CONTRACTORS DECLARATION r DIST NO qc7Y
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS d
(commencing with Section 7000)of Division 3 of,the Business OUTLETS OVER
and Professions Code,and my license is in full force aryd effect. 5 PER SYSTEM. FINAL,4 V DATION
i
Q Gt DAT C
License Number J 1 Lic. Class a
7i• FINA L
Contractor
�O 'p, Date BY
❑ I am exempt under Sec. H
B.BP.C. for this reason Plan check fee d
Date: cor
PLUMBING PERMIT ISSUING FEE$ a Q
Signature TOTAL FEE10 v X 5 0 7.7 A
• �
SINGLE FAMILY # 000005
i Plan check applicant HOME OWNER-BUILDER DECLARATION Name ( o - 9600
I hereby affirm that I am exempt from the Contractor's LicenseAddress o 0 o 96,0053
Law for the following reason (Section 7031.5, Business and -
Professions Code): City Tel. No. 0 7 1 7 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 Stote laws regulating Plumbing, and hereby
authorize'repre'sentatives of this County to enter upon the
N\a ove-m property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
tignature of Permittee Date