HomeMy Public PortalAbout5568 WELLAND AVE_Plumbing__ •VJORKERV COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
1.heraby,affirm that I have a certificate of consent to self 7BA667A
insure, or,a.,grfificote of Workers'Compensation Insurance, CE 817(REV.8/86) �J
br a certified copy thereof(Sec. 3800, L�b,. C.)
PolicyNb.- t4Z� Company G'�t/L Y11.rJV, ( COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby furnished. /� A .
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDIN6ADDRESS
\ •J � �/��-pC!
Certified copy is filed with the county building inspec-
tion department. I UMBER FIXTURE OR ITEM (ap FEE LOCALITY '
r/� WATER CLOSET
Date — ` Appligant NEAREST I '
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB ,Z d
CROSS ST. t 1
COMPENSATION INSURANCE SHOWER OWNER ,t S ®Eu
(This section need not be completed i6 the work involved by MAIL _
the permit is for one hundred dollars($100)or loss.) LAVATORY ADDRESS3 S�`}N :J& i! c
I certify that in the performance of the work for which this a
permit is issued,I shall not employ any person in any manner i SINK CITY � ,96 t TEL. NO. 2 (O�j
so as to become subject to the Workers'Compensation Laws. DISHWASHER tJQ
CONTRACTOR Pc,/,/y{6 1_"J(„•,
DateApplicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS V / ��� 7V�dl�
you,
Exem tionshould become subject to the Workers' SWIMMING POOL RECEPTOR TQ
Exemption, Y I CITY TEL. NO..7721-SZ6
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM �Q0�
with comply with such provisions or this permit shall be STATE IIIUC.?�� L
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRLT NO. :.OZCES, D BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM SOUTLETS 0
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and err ct. 5 PER SYSTEM FINAL LIDATION
� �
GC3 L
License Number � V-11.1c. Class DATE
IV
C.idn "__'_ —3 -7
FIN
Contractor 20 � Date �UQ BY F�
❑ L7
I am exempt under Sec. �
t9J
B.BP.C. for this reason �
Plan check fee a 6 7 6,6 A c
Date: PLUMBING PERMIT ISSUING FEE$
Signature # o 0 0 0 0 5
TOTAL FEE
Plan check applicant '
I ° ° 81350
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name ° ° ° 8 a 5 0 5
I hereby affirm that I am exempt from the Contractor's License Address 0 330-87
Law for-the following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
❑ 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 State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-menti ned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
3--36-9-7
Sign Lure of Permittee Date