HomeMy Public PortalAbout6273 AVON AVE_Plumbing_2/25/1992_ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that i have a certificate of consent to self 20-0026 DPW 6/87
insu`re,,or a certificate of Workers' Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800, b. C.) �e_ COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No.�3»- Company
Certified copy is hereby furnished. BUILDING \!l4
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS x CJ
-Certified copy is filed with the county building inspec-
!�`-' tion de artment. //�� �►� NUMBER FIXTURE OR ITEM @ FEE LOCALITY i
Date l 7,Applic.nt Olt21_ ` 6 WATER CLOSET NEAREST f�
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER
-
(This section need not be completed if the work involved by MAIL / n
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS 7 .
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY 1 TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHERL
CONTRACTOR
DateApplicant CLOTHES WASHER ADDRESS �� S t.
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR !� �
Exemption, you should become subject to the Workers' CITY TEL. NO. �
r
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION / DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 4-19,f
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and'effect. 5 PER SYSTEM FINAL VALIDATION
DATE
License Number — Lic. Class S'� 0.
�
I FINAL
Contractor /`MVf � Date Z� BY
/� �.
❑ ��
I am exempt under Sec.
B.&P.C. for this reason
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature Ll
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name /•`;' s
xiwr
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. T
f!
❑ 1, as owner of the property, will do the work and the - ,
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY - -
I hereby affirm that there is a construction lending agency for ',•ii kW]C
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name is j'w_I- }';:+•z - _,e::';`--
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-mention 'prop y for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Pon,ittee Date