HomeMy Public PortalAbout5637 SANTA ANITA AVE_Plumbing__ J
WORKER'S COMPENSATION DECLARATION 76AA657A DPW 9189 APPLICATION FOR PLUMBING PERMIT
I Hereby affiryi t1tat t have a certificate of consent to self Insure,
or a certificate of Worker's Compensation Insurance,or a certified
copy thereof(Sec.3800 Lab.C.)
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
Policy No IC440 la Company
- if I❑ Certified copy is ereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS .�
Certified copy is filed with the county building inspection
de artm nt. NUMBER FIXTURE OR ITEM @ FEE
�y,��� LOCALITY
Date S'� Applicant Al— L� "`� WATER CLOSETQ
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE BATHTUB ASSESSOR 2 �.f��
(This section need not be completed If the work Involved by the Gv / 0 b MAP BOOK j PAGEv. / PARCEI.9590
permit is for one hundred dollars($100)or less.) D OWNS70
I certify that in the performance of thework for hich this permit LAVATORY
Is Issued, I shall not employ any person in a y manner so as to �IroK MAIL
1 Q ADDRESS
become subject to the Workers'Compensation L s.
Q CITY TEL.NO.
Date J Applicant g CLOTHES WASHER CONTRACTOR A
NOTICE TO APPLICANT: If, after/drevoked.
q this C tificate of
Exemption,you should become subject Worke Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code,you muhwith comply with such I !7
provisions or this permit shall be deem. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY He AJV16,0 Te76NO.2/3- �
WATER HEATER
I hereby affirm that I am licensed under provisions of Chapter 9 � 00 STATE LIG,1'+TT•'Y° s C�
(commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO. d CIQ19S i a s L? (,
Professions Code,and my license is in full force and effect.
OUTLETS OVER DISTRICT*�. P �CIFs.6SE B� 48-2.611D
O 5 PER SYSTEM � — C 10
License Number Lic.Class
FINAL
/ ���� D DATE I _ VALMMION a
Contractor 1" 1"e tC v"Date r7 �p L.,�� _Cc
❑ FINAL / u•'U°'��r Z
07
I am exempt under Sec. FI
B.&P.C.for this reason �, 2 ITEMS
Plan check fe "�
16:4-
Date: _ T��riL 1•�t�°�•a
Signature PLUMBING PERMIT ISSUING FEE$ o1 6 , CHECK 278.25,
❑ TOTAL FEE �� CHf"�NG ,13 j
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name 00000-0001 11' 51193,
1 hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5, Business and Professions Address 0,546 1 AM :21
Code):
❑ City Tel.No.
1,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 reg Iating Plumbing, and hereby authorize
representatives of th County to enter upon the above-mentioned
property for inilpecVn purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sinnefnr of Permit ea Date