HomeMy Public PortalAbout6145 AVON AVE_Plumbing__ (2) WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
Wter?a, affirm that I have a certificate of consent to self 76A667A
insurea or a certificate of Workers Compensation Insurance CE 817(REV 10/81)
or a certified copy thereof (Sec 3800 Lab C ) a COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company '
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
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Certified copy is filed with the county building inspec ADDRESS S UQ/V 1-
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tio deartment NUMBER FIXTURE OR ITEM
FEE/M� NEAREST LOCALITY
Date Applicant WATER CLOSET 00 w
CERTIFICATE OF EXEMPTION FROM WORKERS +
BATH TUB 00 CROSS RqL
COMPENSATION INSURANCE SHOWER OWNER
Tis section need not be completed if the work involved by MAIL i
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the permit is for one hundred dollars (;100)or less ) LAVATORY ADDRESS i
1 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 _7&' ij::�7 TEL NO:;'�–
so as top—ofne subject to the Work Compensation DISHWASHER
CONTRACTOR
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Date9'6 Applicant CLOTHES WASHER ADDRESS !
NOTI T APPLICANT If after making this Certificate of
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
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with comply with such provisions or this permit shall be STATE LIC i
deemed revoked WATER HEATER, LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION t DISTRICTO,)�/ P ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS TVI
" (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 DATE
L / VALI TION 0
License Number Lic Class 6 U
FIN OC
Contractor Date BY 0
❑ I am exempt under Sec YU,e
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B&P W C for This reason Plan check fee Z
Date �
Signature PLUMBING PERMIT ISSUING FEE$ (� ;24 3 Q 3 A
TOTAL FEE # 0 0 0 0 0 5
Plan check applicant r o
SINGLE FAMILY ' - 2a50
HOME OWNER BUILDER DECLARATION Name O 5
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e o 0 2 8 5
I hereby affirm that I am exempt from the Contractor s License Address
Law for the following reason (Section 7031 5 Business and
Prgfessions Code) City Tel No 3 7 8 6
I as owner of the property will do the work and the Q i
structure is not intended or offered for sale (Section Pilo
Business and Professions Code) g
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued _
(Sec 3097 Civ C )
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Lender s Name
Lenders 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
e mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Permittee D to r