HomeMy Public PortalAbout6111 AVON AVE_Plumbing__ A WORKER'S COMPENSATION DECLARATION 20-0026 DPW 9/89 APPLICATION FOR PLUMBING PERMIT
76A667A
I hereby.affirm that I have-acertificate of consent to self insure,
or a certificate of 1N6rker's Compensation Insurance, or a certified
colyfhereof(Sec.3800 Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
Policy No. Company
Certified copy is hereby furnished. BUILDING
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 0
Certified copy is filed with the county building inspection
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY /
Date Applicant WATER CLOSET Or NEAREST �lv
CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' 6. BATH TUB _ �/
COMPENSATION INSURANCE ASSESSOR
PAGE OD �}r/l�
(This section need not be completed if the work involved by the
SHOWER PARCE
permit is for one hundred dollars($100)or less.) l OWNER 111��� VV WA 14
1 certify that in the performance of the work for which this permit .5 LAVATORY
is issued, I shall not employ any person in any manner so as toSINK MAIL Z
become subject to the Workers'Compensation Laws. ADDRESS
' DISWASHER CITY C tAp i TEL.NO.fete s).yb
Date Applicant I - CLOTHES WASHER 7 d
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR 140-41-ACI—Cf
Exemption, you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO.
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER
(commencing with Section 7000) of Division 3 of the Business and STATE LIC.
Professions Code,and my license is in full force and effect.
GAS SYSTEM OUTLETS LICENSE NO. CLASS 0
OUTLETS OVER DISTRICT NO. PROCESSED BY CC
5 PER SYSTEM
License Number Lic.Class r3 0_5 E 81
FINAL ,
DATE VALIDATION LU
p
Contractor Date (J (1)
ElI am exempt under Sec. p BY AL
B.&P.C.for this reason a
Date: Plan check fee
Signature PLUMBING PERMIT ISSUING FEE$ d?(G O
r_1TOTAL FEE /
17
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name �?!_.S,°s ,T
hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions Address .ry
Code):
City Tel.No. ___
I,as owner of the property,will do the work and the structure � C
Ir.is not intended or offered for sale (Section 7044, Business oil. E(!'i NL 4 12 = 6=r-
and Professions Code). ,.
CHEK
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
u
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
representa'v s of his C unty to a ter upon the above-mentioned 9
property fo i eco p po as. SEE REVERSE FOR EXPLANATORY LANGUAGE
I� �3- �
Signature of Permittee Date