HomeMy Public PortalAbout6133 AVON AVE_Plumbing__ ION
DECLARAT
WOthatI have
aceSATate of consent to 76A666DPW9/89 APPLICATION FOR PLUMBING PERMIT
76A667A
I hereby affirm that I have a certificate of consent to self insure,
or-a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec. 3800 Lab. C.)
V
Policy No.
h - LMany S` COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
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IL�J Certified copy is hereby furnished. f�`-�— %•3 BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS ('13 �J oo
Certified copy is filed with the county buil inspection
department. NUMBER FIXTURE OR ITEM @ FEE
h ,q LOCALITY Tr.JI.
/e C.
Date f V—S (,Applicant PI WATER CLOSET_ / NEAREST l
CROSS ST. �YJ�pC
CERTIFICATE OF EXEMPTI N FROM WORKERS' BATH TUB
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) OWNER
�-�CJ I •�
I certify that in the performance of the work for which this permit LAVATORY MAIL C
is issued, I shall not employ any person in any manner so as to SINK CJ �
become subject to the Workers' Compensation Laws. ADDRESS
DISWASHER CITY TEL.NO.,�S-75-7/t
Date Applicant CLOTHES WASHER CONTRACTOR
NOTICE TO APPLICANT: If, after making this Certificate of I
Exemption,you should become subject to the Workers' Compensation SWIMMING POOL RECEPTOR DA
provisions of the Labor Code, you must forthwith comply with such ADDRESS 711 11._ A)6. Z+'�l
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM 1 �dt� /
LICENSED CONTRACTORS DECLARATION CITY TEL.NO. �-
1 hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER7(156
n-
(commencing with Section 7000) of Division 3 of the Business and STATE LIC. O
GAS SYSTEM OUTLETS LICENSE NO. 5�� CLASS
Professions Code,and my license is in full force and effect. V
OUTLETS OVER DISTRICT NO. PROCESSED BY
5 PER SYSTEMJ�J
License Number " d� L / Lic.Class )I " L�� O
S
DATE VALIDATION a
FINAL
1 S t� Ms D ('�
Contractor ate C0
`
am exempt under Sec. FINAL ZBY
BAP.C.for this reason S`
Plan check fee
Date:
Signature
PLUMBING PERMIT ISSUING FEE$ 4( 11
❑ TOTAL FEE
91—
SINGLE FAMILY rn
Plan check applicant
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 Professions Address
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). ,
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 N bf __
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 law regulating Plumbing, and hereby authorize
representatives o this County o enterp the above-mentioned
purp a
property for inspec SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of ermittee Date