HomeMy Public PortalAbout5325 ZADELL AVE_Plumbing_9/27/1991_ 'WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
bhefeby'affirrh that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers'Compensation Insurance, 7BA667A
or a cer)ified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished. BUILDING
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) .� �•7 � V�
Certified copy is filed with the county building inspec- ADDRESS _�
tion department. C NUMBER FIXTURE OR ITEM @ FEE LOCALITY
�wAppligant I SES�� /LC WATER CLOSET
Date S_11' NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 3 CROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be completed If the work Involved by MAIL
SHOWER
L? the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS t LLe
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR /
Exemption, you should become subject to the Workers' CITY LTEL. NO. a
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM �`'' �8
with comply with such provisions or this permit shall be STATE NO. �T LIC « ���
deemed revoked. WATER HEATER
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS z p
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER d
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
DATE Z7
License Number Lic. Class
_ C� FINAL 0'
Contractor Z It e ie Date �7'� r BY
❑ I am exempt under Sec. W
B,BP.C. for this reason
Plan check fee C0 to
Date:
PLUMBING PERMIT ISSUING FEE$
Signature . . ___ 1
TOTAL FEE
Plan check applicant _
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name ,• a
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address -
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). _ _r_
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for L��N�•a�
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address "'7` j Fir: `rO
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County 0111.
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-motioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Si Date