HomeMy Public PortalAbout6002 AVON AVE_Plumbing_3/9/1995_water heater WORKERS'COMPENSATION DECLARATION APPLICATION FCR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consent to self in- 76A�667A PW 4/90 /��
sure,or a certificate of Workers'Compensation Insurance,ora --; �
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 inspection ADDRESS V O 4 G�
department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
WATER CLOSET(TOILET) -
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST._ �
COMPENSATION INSURANCE SHOWER . OWNER _577
(This section need not be completed if the work involved by MAIL c�
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS ✓ � �_
I certify that in the performance of the work for which this per- SINK CITY TEL. NO
mit is issued, I shall not employ any person in any manner so
as to become subject to The Workers'Compensation ws. DISHWASHER /
CONTRACTOR
Date / Applicant CLOTHES WASHER
ADDRESS,?��/�f
NOTICE TO APPLICANT: If, after mak Ag this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen.- CITY TEL. NO. -
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE /�Jp�G� LIC.
ed. WATER HEATER LICENSE NO. C� CLASS 61
LICENSED,CONTRACTORS DECLARATION �� DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter TSOVER OUTLETS G
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER d
and Professions Code, and my license is in full force and ef- 5.PER SYSTEM FINAL VALIDATION
fect. � 7 HOSE BIB DATE t 3�
License Number 10a �G Lic. Class (�cT�, 0
FINAL O
Contractor Date �C BY Cc
O
I am exempt under Sec. %, C.-
U
B.&P.C. for this reason ► 3'�"17 + W
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE aSINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name (jr":r ' o L
Law for the following reason (Section 7031.5, Business and
Professions Code): Address Y sR•a L -
I, as owner of the property, will do the work and the City- Tel No. ^E�t`4
structure is notintended or offered for sale(Section 7044,
i •.'
Business and ProI'
AT
Code). `► , :
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency forl€
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name i i (3 :r iY
--- _ 7''.
Lender's Address
I certify that I have read 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
above- on ro for inspectioZpuroses, SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign ty a of Permittee �D=ate —f—