HomeMy Public PortalAbout6002 AVON AVE_Plumbing_11/2/1989_lawn sprinkler system, water svc WORKERS'COMPENSATION DECLARATION
4DPW 4/87 APPLICATION FOR PLUMBING PERMIT �t
I hereby,"5jT"iarq,that I have a certificate of consent to self in- 76A6676A667A
sore,or a'certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86)
c€!rtifjed copy?hereof{ ec. 3800,•Lab. C.) ,
Policy No11) Company.` %ArA1[�t"1•A- (c3 COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
E] Certified copy is hereby furnished.
j FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
�ertified copy is filed with the county building ins ectio ADDRESS �J/j� �C /_
department. NUMBER FIXTURE.OR.ITEM @ FEE
(—� j LOCALITY
Date l/jam — U ApplicantJlY1�r r ,� WATER CLOSET(TOILET) NEAREST
CROSS ST
TUB. .
' CERTIFICATE OF EXEMPTION FROM WORKERS' BATH -
COMPENSATION INSURANCE SHOWER OWNER j LA-) rL- (7L) r >✓
(This section need not be completed if the work involved by MAIL / G� 2 � .;./ h
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS (Q o A
I certify that in the performance of the work for which this per-
SINK CITY �i' /" TEL. NO. •�
mit is issued, I shall not employ any person in any manner so r,•W( .(�
as to become subject to the Workers Compensation Laws. DISHWASHER /
CONTRACTOR r2((
Date Applicant CLOTHES WASHER ADDRESS`36 ,12 Z ��N r`CiYi
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption,
x- SWIMMING POOL RECEPTOR
em tion,you should become subject to the Workers'Com en- + G (/
P Y I Compen-
CITY g•✓1.r; �j�j_ (�,v TEL. NO." '?'�T vn / �T
sation provisions of the Labor Code, you must forthwith comp- � LAWN SPRINKLER SYSTEM '7"''
ly with such provisions or this permit shall be deemed revok STATE y LIC. 1
ed. WATER HEATER LICENSE NO. cid CLASS ::/' J
LICENSED CONTRACTORS DECLARATION DI�TRICZNO,. J ESE BY
I hereby affirm that I am licensed under prov.isions of-Chapter GAS SYSTEM OUTLETS c✓C] l//�.//)! (/�(
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER o
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM ii FINAL, ALIDATION
fect. L/ {� �� UJ/C DATE � �.�, O
License Number ('iJ�Vc Li� C_lassy V
Contractors
- -1 5'?T�
,Las
�� BY AL O
I om exempt under Sec. LU
LU
B.BP.C. for this reason ► ca
Plan check fee
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 ; ;04
Professions Code): Address
7 2
Cit Tel. No. �u e•`_'•L)
I, as owner of the property, will do the work.and the Y "
structure is not intended or offered for sale(Section 7044, - 1 ITE.IIS'
Business and Professions Code).
IlT{
8 28. 50
CONSTRUCTION LENDING AGENCY
CHECK
`!I
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued L; H�E o ;;I}
(Sec. 3097,.Civ. C.).
Lender's Name 0000- 001 1 / 2/83'
Lender's Address6540 i �`�� oLs
I certify that I have r d this/aplc, on a d state that the
a ve formation i correct. I om ly with all County
divan es'and St to I ws relu Bing, and hereby
uthon repres tati es of t to enter upon the
above- ntio • pro erty t purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
i a ure of Permittee Date