HomeMy Public PortalAbout6267 AVON AVE_Plumbing_3/31/1989_bathtub, lavatory, water heater r WPRKERS'COMPENSATION DECLARATION
�14by, ai irm that I have a certificate of consent to self in 20-0026 DPW 4/87 76A667A APPLICATION FOR PLUMBING PERMIT
sure,-or a certificate of Workers'Compensation Insurance,ora CE 817(REV. 8/86)
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
department. NUMBER FIXTURE OR ITEM @ FEE
(�j _ LOCALITY
Date 31"<T7 Applicant WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM W RKERS' , BATH TUB Uv CROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER MAIL
the permit is for one hundred dollars ($100) or less.) i LAVATORY QU ADDRESS
I certify that in the performance of the work for which this perzuml
-
mit is issued, I shall not employ any person in any manner so SINK CITYTEL. NO.
as to become subject to,the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESSSWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY TEL NO. �jC� '
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM fy
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER V� LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION ll DISTRICT NO. R SSED BY
I hereby affirm that I am licensed under provisions of Chapter ---- GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINALVALI A ON y'
fect.
License Number y oZ� 7 Lic. Class DATE 0
O
U
FINAL
Contracto e_, k� Date -q-317–&2– BY O
❑ U
1 am exempt under Sec. LU
B.&P.C. for this reason ,
Plan check fee g
Date: PLUMBING PERMIT ISSUING FEE$ �v
Signature
TOTAL FEE 2Y,
SIN E FAMILY '
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Na e
Law for the following reason (Section 7031.5, Business and
Professions Code): [AdessAI; as owner of the property, will do the work and the y Tel. No. _
structure is not intended or offered for sale(Section 7044, =t)'� 23.5_',_'
Business and Professions Code). ► i T.
CONSTRUCTION LENDING AGENCY 'y1^,i ni tt s
I hereby affirm that there is a construction lending agency for
the performance of the work for which this ermit is issued i;`E 's' –"
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the ► ( ( l`t
above information is correct. I agree to comply with all County
ordinanc and State laws regulating Plumbing, and hereby
author' a representatives of this County to enter upon the
ab e-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o .ermittee Date