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Home My Public Portal About6139 AVON AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A ® as® PERMIT insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) �. or a certifi p thereof Sec. 3800, Lab. C.) r v ��r� r COUNTY OF LOS ANGELES / BUILDING AND SAFETY ❑icy No. Company - Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING / Certified copy is filed with the county building inspec- - ADDRESS ��/ %l2�AJ rJ s tion dep rtm-nt. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET NEAREST y CERTIFI ATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. (/ COMPENSATION INSURANCE SHOWER OWNER �� U •� ` ' �S� (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO. so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTORe 07'-'" ./' tO �1JI4 Date Applicant CLOTHES WASHER i`� 4 ADDRESS S S 7— NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY Compensation provisions of the Labor Code, you must forth- ,� W TEL. NO. g '—�r�fl LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATELIC. deemed revoked. WATER HEATER LICENSE NO. ? CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. OCESSED BrY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000 of Division 3 of the Business J a� >_ ( 9 ) OUTLETS OVER 0- and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINALVALIDATION O License Number S 37 Lic. Class✓ DATE FINAL Contractor Datelkb_ 3 BAM Y AM ❑ I am exempt under Sec. ` B.&P.C. for this reason Plan check fee Date: PIP �{ /� PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address �' �,4 A Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. tt o o'0 0 0 ❑ I, as owner of the property, will do the work and the 2 0 02,250 0 structure is not intended or offered for sale (Section 7044, Business and Professions Code). PIPo o o 2 2 5 0 cs CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for Q 2 2 B—8 3 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 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-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee D e WORKERS'COMPENSATION DECLARATION 7ew6e7w I hereby affirm that I have a certificate of c6n0nt to self CE e» (21180) i-A P P L I C A T I O N FOR PLUMBING PERMIT insure, or a certificate of Workers'Compensation Insurance,or --r 'fl a certified copy thereof(Sec. 3800,Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY 512- No. (3 2_0? y w F1 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING j ADDRESS Certified c py is filed with the county uil inspecti n NUMBER FIXTURE OR ITEM i FEE dep rt e7 P WATER CLOSET LOCALITY L Date 2- 2 pplicant NEAREST BATH TUB CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER OWNER y S-S°A" LAVATORY MAIL' (This section need not be completed if the work involved LADDRESS � by the permit is for one hundred dollars ($100) or less.) SINK CITY TEL. NO. 0 I certify that in the performance of the work for which this DISHWASHER ��r permit is issued, I shall not employ any person in any manner CONTRACTOR 0 7 D G!� ��® U CC so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER ADDRESS S Date Applicant SWIMMING POOL RECEPTOR Q () NOTICE TO APPLICANT: If, after making this Certificate of CITY ��,8 �-� TEL. NO. ly Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE / LIC. CL LICENSE provisions of the Labor Code, you must forth- ENSE NO. 3et 3/ CLASS (I�C with comply with such provisions or this permit shall be WATER HEATER 7 deemed revoked. DISTRICT NO. PR CESSED Y GAS SYSTEM OUTLETS LICENSED CONTRACTORS DECLARATION OUTLETS OVER 10k I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Bdsi- FINAL VALIDATION ness and Professions Code, and my license is in full force and e�P/ �� DATE 2 effect. s3`� 3 37 C_34 X.41 i FINAL License Number l Lic.Class. BY Contracto AA� Date ElI am exempt from the licensing requirements as I am a Plan check fee v f 1 licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ SO acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE V Lic.or Reg.No. Date Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's Address License Law for the followingreason Section.7031.5, Busi- O 0 5 1 A ( City Tel.No. ness and Professions Code): I, as owner of the property, am exclusively contracting ?; 0 0 0 0 0 with licensed contractors to construct the project (Section 7044,Business and Professions Code). 2 0 0 3 O,5 O CONSTRUCTION LENDING AGENCY uc ° 0 3 O.5.0 v I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 0 2 2 4 8 3 issued(Sec. 3097,Civ.C.). Lender's Name ,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 SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above- ent'one property for ins ction purpos s. ignature of Permittee Dat