HomeMy Public PortalAbout6267 AVON AVE_Plumbing_12/5/1989_dishwasher, clothes washer rf WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that-I have a certificate of consent to self in- 76A6PW a/87 67A L^�I
j owre,or a certificate of Workers`Compensation Insurance,or a CE 817(REV. 8/86) U
certified copy thereof (Sec. 3800,Lab.L.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDI,
-Certified copy is filed with the county building inspection ADDRES
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 ��AO/?0,
This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS !/
'023� 40 77
I certify that in the performance of the work for which this per-
SINK '
as to become subject to the Workers' Compensation.Laws. / DISHWASHERTO—
CONTRACTOR
Date Applicant CLOTHES WASHER 10 U ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption,you.should become subject to the Workers'Compen- . CITY TEL. NO.
sat,ion provisions of the Labor Code,.you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be.deemed revok- STATE UC.
ed: WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION' DISTRICT NO ROCESSED BY
I hereby affirm that I am'licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL V IDATION
fect. DATE
License Number. Lic. Class O
FINAL ' U
Contractor Date BY p
0
I am exempt-under Sec. V
651
B.BP.C. for this reason ►
Plan check fee g
Dater PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicants
I hereby affirm that am.exempt from the Contractor's License Name
Low for the following reason (Section 7031.5, Business and M1 £_.
Professions Code):. Address 22 .50
y2°•-'(=
RX 'I, as'owner.of the property, will,.do the work and the City -Tel. No. 1 ITEM
structure is not intended or offered for sale(Section 7044,
Business and Professions Code) {OTA(_ 22 - 50
CONSTRUCTION LENDING AGENCY , -HECK .4?
I hereby affirm that there is a construction lending`ogency for t=HANGE
Oct
jc; -
the performance of the work for which this permit is issued
(Sec. 3097, Civ..C.).
Lender's Name 0 M-0001 12/ 5/89
Lender's Address y/y 1 P}�.•i� °s t,. .
I certify that I have read this application and state that the
abl
ove information is correct. .agree to comply with all County ,
ordinances and State laws regulating Plumbing;-and hereby
authorize representatives of this County to 'enter,upon the
9bove-Enentioned prop rty for inspection purposes.
SEE.REVERSE FOR EXPLANATORY LANGUAGE
Signature 0 ittee Date