HomeMy Public PortalAbout5927 AVON AVE_Plumbing_6/22/1995_gas system WORKERS'
rm'tha COMPENSATION DECLARATION
ent APFUCATPON FOR PL p�/�MIG PERNT
I hereby, affirm'that I have a certificate of consent to self in- 20-0026 DPW 4/90 �j1"• PLUMMIG tla
sure,or a certificate of Workers'Compensation Insurance,or a 76A667A
certified copy thereof (Sec. 3800, Lab. C.)
,?/L �`' J . COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Companyh�crrriy�9lt
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
.gj Certified copy is filed with the county building inspection ADDRESS
department. NUMBER. FIXTURE OR ITEM @ FEE LOCALITY
Date APPlicont, ? WATER CLOSET.(TOILET) NEAREST;
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNERS/,�-
(This section need not be completed if the work involved by MAIL 7
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS/
I certify that in the performance of the work o;rwhich this per-
mit is issued, I shall not employ any person in any manner so SINK CITYJolly_ TEL. NO,,,;
as to become subject to the Workers'Compensation Laws. DISHWASHER /
Date Applicant CLOTHES WASHER
ADDRESS �a� �
NOTICE.TO APPLICANT: If, after making,this Certificate of Ex- SWIMMING POOL RECEPTOR f�f�-
emption,you should become subject to the.Workers'Compen-
/� L J
cation provisions of the Labor CodCITY �����`� TEL. NO.D"�/✓e, you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE � CIC.
ed. WATER HEATER LICENSE NO. � '8� CLASS
LICENSED.CONTRACTORS DECLARATION, l DISTRICT NO. PROCESSED BY
GAS SYSTEM OUTLETS A Y
I hereby affirm that 1 am licensed under provisions of Chapter l� o
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER.
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL �l
fect. ' HOSE BIB DATE. �'FZ
License Number��/��S Lic. Class/��C VALIDATION
0
FINAL. O
Contractor ` DateBY
1. / /" Z. O
El I am*exempt under Sec. fLU
fi V
B.&P.C. for this reason Plan check fee
y
Date: PLUMBING PERMIT ISSUING FEE$
Signature TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant '
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section.7031.5, Business and
:-
Professions Code): Address
❑ I, as owner of the property, will-do the work and the City Tel. No.
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
Lender's Address
I certify that I haveread 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 i
above-m tioned property for i spection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date.