HomeMy Public PortalAbout5572 WELLAND AVE_Plumbing__ &VRKERS''COMPENSATION'DECLARATION APPLICATION FOR PLUMBING PERMIT
Hereby;affirm ih4.l'Fidxe a certificate of consent to self% 76AS67A
insure,,orypD'erfificate bf Workers'Compensation Insurance, ', CE 817(REV.8/86)
ol o'certified copy thereof(Sec. 3800, Lab. C.) _
Z� '• �'�/� �Ei1,5uN( COO.yR9YV OF LOS ANGELES 'DEPT. OF PUBLIC WORKS
Rol'cy No.� Company ti
Cefi4led copy is hereby furnished. .
�� FOR APPLICANT TO FILL IN(PRINT-OR TYPE) BUILDING
❑ �Cerfified copy is filed with the county building inspec- ADDRESS
/ •• hon department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
ate ^ `8 Appligant - v WATER CLOSET ® NEAREST
9 CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB Z CROSS ST. .
COMPENSATION INSURANCE SHOWER OWNER Pau
/(This section need not be completed if the work Involved by (� /) _
the permit is for one hundred dollars($100)or less.) LAVATORY (� ADDRESS J SRS►
I certify that in the performance of the work for which this
permit is issued, I shall.noY employ any person in any manner l SINK00 CITY 'C( TEL.NO.
so as to become subject to the Workers'Compensation Laws:
t DISHWASHER �) CONTRACTOR `N
Date Applicant CLOTHES WASHER ADDRESS J31 G f✓A,0S�JNA
NOTICE TO APPLICANT: If, after making-this Certificate of SWIMMING POOL RECEPTOR _
Exemption, you should become subject to the Workers' n R
Compensation provisions of the Labor Code, .you must forth- LAWN SPRINKLER SYSTEM CIT! l�-L .� � �� TEL.NO. S• 2,�) � .
'with comply with such provisions or this permit shall be STATE LIC. •�C
deemed revoked. WATER HEATER LICENSE NO. , Z°� CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT N .� P ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS -
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER �� 3i
and Professions Code,and my license is in full forcerid effect. 5 PER SYSTEM FINAILL
bAdl TION
c DATE v
License Number p 75 Z Lic. Class
17_
I Contractor A Date ,
❑ W
I am exempt under Sec. CL
e.aP.C. for this reason ra
Plan check fee �6 7 b 2 p
Date: PLUMBING PERMIT ISSUING FEE$ 0 0 0 0 0
Signature TOTAL FEE # 5
• 88.50 -
Plan check applicant
SINGLE FAMILY 0 0 0 $$ 5 0 c=i
HOME OWNER-BUILDER DECLARATION Name .
I hereby affirm that I am exempt from the Contractor's License
Law for.the following reason (Section 7031.5, Business.and Address330-87
Professions Code): City Tel. No.
❑ I, as owner of t1he 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, D
.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
abov mentio ed property for inspection purposes.
��� SEE REVERSE FOR EXPLANATORY LANGUAGE ,
Signature of Permittee Date �� ,,