HomeMy Public PortalAbout5930 AVON AVE_Plumbing_4/17/1986_water heater WORKcRS'COMPENSATION DECLARATION APPU AYPON FOR PLU o � I P�c�Rll T
I hereby, aff9 n that I have a certificate of consent to self 76A667A //v uV' u ❑Vll v LS I1VLl
insurt, or o,certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof (Sec.3800,1 Lab. C. / /J COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Policy N � Company�A1,ff, Z/Vt���. 610,
❑ •Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county buildipl inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY
WATER CLOSET ,
Date
//// Applica �" NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER y
(This section need not be completed if the work involved by Cr
the permit is for one hundred dollars $100 or less. MAIL
P ( � ) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY 1TEL.
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS �f1
NOTICE TO APPLICANT: If, after making this Certificate of / SI-71111
Exemption, you should become subject To the Workers' �� L �
f� SWIMMING POOL RECEPTOR
ll
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY ; r e. TEL. NO� _4557
with comply with such provisions or this permit shall be STATE LIC. [✓
deemed revoked. gq WATER HEATER LICENSE NO. � CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. SSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of.the Business OUTLETS OVER 0.
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
/)"7�� DATE VALIDATI V
License Number JAQ / Lic. Class
J (1L�L-/ll(T.C I b Date FINAL
Contractor �- BY F'
U
❑ uy
I am exempt under Sec. �
B.BP.C. for this reason Plan check fee Z
O D 445,bA
TOTAL FEE �
Date: PLUMBING PERMIT ISSUING FEE$
Signature &S- # o 0 0 0'0 5
SINGLE FAMILY
Plan check applicant 1.o ° 1 6.5 0
_ '
HOME OWNER-BUILDER DECLARATION Name ° 0 00 5 0
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and 4 1 7-8 b
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 D
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 have read this application and state that the D
above information is correct. I agree to comply with all County
ordinaW
laws regulating Plumbing, and hereby
authorives of this County to enter upon t
ab pert or i pectio u poses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signat of Permittee Date ,/ 7A?6