HomeMy Public PortalAbout5566 WELLAND AVE_Plumbing__ ` 'WORKkRS'CbMPEIVSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I ;hereby,affirm that I-liave a certificate of consent to self 76AS67A
insure, or a Nortificale of V/orkers'Compensation Insurance; CE 817(REV.8/86)
tisti-d`' u
or a certicopy thereof(Sec. 3805, Lab. C.)
'L�t16 �At/1,ywoufv j COUNTY OF LOS ANGELES DEPT. OF•PUBLIC.WORKS
Policy No. _Company _ `
*ILZ7� Certified copy.is hereby furnished.
R TYPE)
FOR APPLICANT TO FILL IN(PRINT OBUILDING
❑ Certified copy is filed with the county building inspec- ADDRESS
In part NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date ^�' Appli4ant . WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' L BATH TUB 00 CROSS ST.
COMPENSATION INSURANCE OWNER -f S L) r
(.This section need not be-completes!if the work Involved by SHOWER / /� p. n n
the permit Is for one h0hdred dollars($100)or less.) LAVATORY O IL
ADDRESS+ 'V ��l'J 6,4/J nl h C
I certify that in the performance of the work for which this1.r
permit is issued, I shall not employ any person in any manner SINK d CITY 'L TEL.NO.PY-SI L•S26
so as td become subject to the Workers'Compensation Laws. DISHWASHER. n
CONTRACTOR L V /71r/4
Date Applicant CLOTHES WASHER ADDRESS 2Jb(l G Igp S GJ.0
a.
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR"
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
LAWN SPRINKLER SYSTEM CITY �`trr ✓� n-vT TEL.-NO. �� —SZ�'3
with comply with such provisions or this permit shall be STATE • 9 LIC, n 7
deemed revoked. WATER HEATER LICENSE 00. S `� CLASS ` J
LICENSED CONTRACTORS DECLARATION G DIST N4,r• P ESSED Y
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS v _ `�1
(commencing with Section 7000)of Division 3 of-the Business OUTLETS OVER v
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VAL ATION
3 . J
License Number ` ( 315Zg DATE Lic. Class C
p FIN
Contractor D Y �"�°�at `Date B - C
❑ I am exempt under Sec. CL
CL
B.BP.C. for this reason
Plan check fee
Date: PLUMBING PERMIT ISSUING.FEE$
Signature �6 7 6'7 A
TOTAL FEE S # 0 0 0 o 0 5
Plan check applicant
SINGLE FAMILY ( 0.0 8 a 5 O
HOME OWNER-BUILDER DECLARATION Name o o - 8a5 p
1 hereby affirm that I am exempt from the Contractor's License Address
Law for-the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. 0 a 7J O i-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
1 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 of this County to enter upon the
a ve-menti ed property for inspection purposes. C SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date