HomeMy Public PortalAbout5564 WELLAND AVE_Plumbing__ ' VUQRKERV COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
�0,Hdreby,'affirm that 1 have a certificate of consent to self 76AS67A
insure, or q cerjificote of Workers'Cgrnpensation Insurance, CE 817(REV.8/88) �l
or a certified copy'thereof(Sec.9800, Lab. C.) �. � -�. '
�q7.°t`Z6 C.) �'►�alJM.r COUNTY OF LOS ANGELES DEPT. 66P`64L@C• WORKS
Policy No. Company
lfLaT Certified copy is hereby furnished. _
BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE)
❑ Certified copy is filed with the county building inspgc-. ADDRESS
tiori department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
WATER CLOSET. Il
Date Appligorit 'NEAREST' I -
CERTIFICATE OF EXEMPTION FROM WORKERS' ) 'L BATHTUB• 01— o 0
CROSS ST:,
COMPENSATION INSURANCE - OWNERS, g PY�l
SHOWER
(This section need not be completed if the work involved by MAIL c
the permit is for one hundred dollars($100)or less.) LAVATORY �� ADDRESS J �'U -'' 12!(1 L•
I certify that.in the performance of the work for which this
permit is i sued;I shall not employ an person in an manner SINK , CITY �/� /� TEL.NO.
P g P.-Y YP Y I• � Y7�1 �N �rC � 2 S�4Ob '
so as to become subject to the Workers'Compensation Laws. p DISHWASHER
l CONTRACTOR
Date. Applicant CLOTHES WASHER• 01/ ADDRESS
NOTICE TO APPLICANT.: If, after making this Certificate of A/) S�J.eJI� C
Exemption, .you should ;become subject to the Workers'. SWIMMING POOL RECEPTOR
CITY C-
n� TEL:NO. :S-Cf /�7
Compensation provisions of the Labor Code,.you.must forth- " lr^Lr J Q �k�.Mi �(.Z's�6 J
LAWN SPRINKLER SYSTEM
with comply with such provisionis'or' this permit shall be STATE /,a q �t LIC.
deemed revoked. WATER HEATER LICENSE NO. `� 7 3 S 1, l CLASS
'• I LICENSED CONTRACTORS DECLARATION DIS ICT N .r/ •,PR!;!!:7
Y
I hereby'affirm that 1 am licensed under provisions'of Chapter 9 GAS SYSTEM OUTLETS 0
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
DATE
License Number ` Lic:Class. C 3 •'
f�
FINYV-
Contrcictor Ar"+q'L 9,%C-Date. -3-3c,47 B
❑ I am exempt under Sec.
B.BP..C. for this reason
- Plan check fee `
Date; PLUMBING PERMIT ISSUING FEE$
Signature .
'TOTAL FEE 16 U A
SINGLE FAMILY Plan check applicant # 0 0 0 0 0 5
HOME OWNER-BUILDER DECLARATION Name i o o S.$5.O
I.hereby affirm that I am exempt from the Coritractor's License Address o"o o $$'S O
Law for,the following reason (Section 7031,5; Business and
Professions Code): City Tel. No. O 3 3 O—8 7
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 J 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 of this County to enter-upon the
abrtionedd pr perty for Inspection purposes.
7 SEE REVERSE FOR EXPLANATORY LANGUAGE
r
Signature of Permittee Date