HomeMy Public PortalAbout5930 AVON AVE_Plumbing_8/16/1989_gas system WORKERS'COMPENSATION DECLARATION APPUCAMN FOR PLUMMMIG PERNT
" '7 fiereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800; Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building Lnspec- ADDRESS &F
tion department. NUMBER FIXTURE OR.ITEM n FEE
LOCALITY ��
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST �� 4(S
COMPENSATION INSURANCE OWNER ���� - �
(This section need not be completed if the work involved by SHOWER' U�' &W'
the ermit is for one hundred dollars $100 or less. MAIL �J
P ( ) LAVATORY ADDRES rD
I certify that in the performance of the workforwhich this
permit is issued, I shall not employ any person in any manner SINK CITY �� TEL. NO.
'
so as to become subject to the Wor Co`�-� rica'en Laws. DISHWASHER
v / CONTRACTOR
,(�
Datr�—�V Applica CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this ertificate of ADDRESS
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL. NO.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION - DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. S PER SYSTEM }
FINAL -VALIDATION
DATE . 2 O.
License Number Lic. Class U
FINAL_
Contractor Date BY
I am exempt under Sec. W
B.BP.C. for this reason C91
Plan check fee D en.
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant C
SINGLE FAMILY 5
HOME OWNER-BUILDER DECLARATION Name ACC�os
hereby affirm that I am exempt from the Contractor's License Address i
Law for the following reason (Section 7031.5, Business and tiProfessions Code): City Tel. No. 3307 t °'_ l
EI, as owner of the property, will do the work and the i ITEMS
structure is not intended or offered for sale (Section TOTAL -p
7044, Business and Professions Code). .lL _ -.50
CONSTRUCTION LENDING AGENCY CHEC.f: 16.50
1 hereby affirm that there is a construction lending agency for CHANE
the performance of the work for which this permit is issued C0
(Sec.(Sec. 3097, Civ. C.).
Lender's Namen 4
0000-1��11
81161,36
A
Lender's Address 5097 te e 1`7°
7
1 certify that I have read this application and state that the D rt tr
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
' above tionejprop rty for inspection purposes. `
SEE REVERSE FOR,EXPLANATORY LANGUAGE
azure of PermiIt. Date