HomeMy Public PortalAbout5570 WELLAND AVE_Plumbing__ • '' n5
V)(ORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
a-, I hereby,affirm that I have a certificate of consent to self 76AS67A
insure, o a Lgrfificafe of Workers'gompensation Insurance, CE 817(REV.8/86)
br a certilie`lcopy thereof(Sec. 3800, Lab. C.)
Policy N 4IM2% Company )'AIZ &L-0 COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING }�
Certified copy is filed with the county building inspec- ADDRESS
tion department. 10�5NUMBER FIXTURE OR ITEM FEE
'7 LOCALITY
97 WATER CLOSET 01
Date Appligant `, CROSS NEAREST
t
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB V
COMPENSATION INSURANCE SHOWER OWNER U
(This section need not be complotod If the work Involvod by 2 c (� ,/� �
tho permit is for ono hundred dollars($100)or loss.) LAVATORY ADDRESS �7
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DRESS J J J '• Pj . -Cr• i/�1Lr d: L
I certify that in the performance of the work for which this p I
SINK 6)0 CITY �fFl t TEL.NO. D
permit is issued, I shall not employ any person in any manner Z$S 2 ( b
so as to become subject to the Workers'Compensation Laws. ( DISHWASHER do
CONTRACTOR
Date applicant CLOTHES WASHER O✓/) ADDRESS Z� Vie lJr� s"
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR !
P Y I CITY b� n TEL.NO.S�Z SZO
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM � NQ _ r'r
with comply with such provisions or this permit shall be STATE �j E� LIC.
deemed revoked. WATER HEATER LICENSE NO. [ 2 + CLASS
LICENSED CONTRACTORS DECLARATION 10q DISTRICT NO. bCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETSf(
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
�L
and Professions Code,and my license is in full force and effect. 15 PER SYSTEM FINAL VALI ATION O
License Number ` ` Lic. Class ` " DATE
J �A� j Is¢ FIN O
Contractor P���ta`��Date �-S Q-v 7 B
I am exempt under Sec. A'
B.BP.C. for this reason
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY 2 6 7 6 3 A
HOME OWNER-BUILDER DECLARATION Name # o 0 0 0 0 5
1 hereby affirm that I am exempt from the Contractor's License Address
Law for.the following reason (Section 7031.5, Business and ( 0 0 8 5 0
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the o 0 0 8 a 5 0 53
structure is not intended or offered for sale (Section
7044, Business and Professions Code). o3,30-87
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-me nt•oned property for inspection purposes.
^ r �� ^� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date