HomeMy Public PortalAbout5930 AVON AVE_Plumbing_3/30/1992_fixtures WORKERS' COMPENSATION DECLARATION /pa I�I�Il �C/p\��ON FOR Po fl fl fl11G1 p �(�()G nERIl/1�i^r
I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 uvu u LS vv riv FOR u L�ILJUVII USI Lr ISU\SIIVII Il
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 A
Certified copy is filed with the county building inspec- ADDRESS s 0/V-141/'
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY A� '4 V1—j�/ �?�- L�f J
Date Applicant , WATER CLOSET
t A/673 tJEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST/If us C,4 let 0—W6-A, 0&d
COMPENSATION INSURANCE OWNER
12(This section need not be completed If the work Involved by SHOWER CLyL�'"C�
the permit is for one hundred dollars $100 or less. / MAIL
P ( ) ) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO..'
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOROW
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS
Exemption, you should become subject to the Workers' SWIMMING'POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM
p y p p STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. WCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS f L t
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER .7
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL BALI AYIORI per.;
�_
License Number Lic. Class DATE O,(,.
FINAL
Contractor Date BY
O.
❑ ~
I am exempt under Sec. U
W
B.&P.C. for this reason Plan check fee )
Date: Z
PLUMBING PERMIT ISSUING FEE$
11
Signature 741
FEE re,
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Namea
I hereby affirm that I am exempt from the Contractor's License 1 nL �s •__SI.
Address ,/
Law for the following reason (Section 7031.5, Business and, � a3 O. r Vb i,F;rov y s
Professions Code): n n _ .M._•; -'t-
City �!a-rt.)(�'�4-R/2l£% Tel. N �� �
�y L r i;eti t
l�J I, as owner of the property, will do the work and their
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY ;11"EI".'•1)•-' ? €� '"
I hereby affirm that there i ons Squction lending agency for
�i
the performance of th or fo hich is permit s i s .''••=�,._`: ,, tr;! `,,. __,
(Sec. 3097, Civ.
Lender's Name V
Lender's Addres,53 s _ bl'l !'A A)dZ j,
I certify that I have read this application and state that the D
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-mentio �ertypectionpurposes. •
SEE REVERSE FOR EXPLANATORY LAWGUAGE
s-9 2
S' ature of Permittee Date