HomeMy Public PortalAbout5217 WILLMONTE AVE_Plumbing__ ��_ ,W RKERS'COMPENSATIONDECLARATION 20-0026 DPW 4187 APPLICATION F®R PLUMBING PERMIT
hereby, affAh that I have a certificate of consent to self In 76A667A
sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV,8/86)
certified,copy thereof(Sec. 3800, Lab.-C.) fl -
Co
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No-Mo? mpany
❑
Certified copy is hereby furn.ishecJ.
FOR APPLICANT TO FILL IN'(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspectio NUMBER FIXTURE OR ITEM ADDRESS �.� Al
department. @ FEE .
LOCALITY
Date r Applicant WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION-FROM O ERS'
BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER fitM Q. O
(This section need not be.completed if the work Involved by SHOWER MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS 'Al-
certify
lcertify that in the performance of the work for which this per-.. SINK
mit is issued, I shall not employ any person in any manner so CITY fo TEL.NO.
a's to become subject to the Workers'Compensation Laws. DISHWASHER
• CONTRACT. R IIIr
Date Applicant CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of-Ex- 7 QA.4
emption,you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR
CITY TEL. NO. a
cation provisions;of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMBUZ� q-12-34
ly with such provisions or this permit shall be deemed revok- STATE LIC:
ed. WATER HEATER LICENSE NO..,327,Fg4 CLASS 3
LICENSED CONTRACTORS DECLARATION DISTRICT NO. - OCESSED Y
I hereby-affirm that I am.licensed under provisions of Chapter -GAS SYSTEM - OUTLETS T�
9(commencing with Section 7000)of Division 3.of the Business OUTLETS OVER
and.Professions Code, and my license is 'rn full force and ef- 5 PER SYSTEM FINAL VALIDATION
fect. 1/ DATE
License Numbe. T Lic. ClassAAmo
� FINAL'
Contractor/JJ//yy�� �[� ft 4–COOS Date BY
❑ 1 am exempt under Sec. LU
B.BP.C. for'this reason O
' Plan check fee • .
Date: PLUMBING PERMIT ISSUING FEE$ r Q
Signature TOTAL FEE I 87 1
SI GLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant v6 _
I hereby affirm that I am exempt from the Contractor's License Name �1r T
Law for the following reason (Section 7031.5,. Business and
Professions Code): Address 9too '�_ '•}"
.,•"••;
Cit Tel. No. ,
❑ I, as owner of the property, will do the work and the Y 3 p4
structure is not.intended or offered for sale-(Section 7044; '•r.�r ,-,z s=,,—
Business and Professions Code). `= -e•
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.l. 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-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
If
Signc,ure of e 'tee Date