HomeMy Public PortalAbout6028 BURTON AVE_Plumbing__ WORKERS'that
t I have
acerNcate of co .+ APPLICATION�I It OR PLUMBING PERMIT
II affirm that haver certificate of consent 'o self 7pA6y7A ,
'-`insure, or a certificate of Workers"Compensation Insurance, CE 817(REV. 10%81)' I,, ,
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished.
❑ - FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING n
Certified copy is filed with the county building inspec- ADDRESS / I
tion deportment. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
WATER CLOSET .a
Date Applicant CROSS NEAREST. L�)s TL.E�-1 L
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB
COMPENSATION INSURANCE SHOWER ^� OWNER ' G. �V1,11
(This section need not be completed if the work involved by MAIL ^o
the permit is for one hundred dollars ($100)or less.) LAVATORY
ADDRESS C.._
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK 'Ita
pLe TEL NO. T,i LIE)�77
so as to become subject to the Workers Compensation Laws. DISHWASHER
_ YF{Aq--- CONTRACTOR
Date -S ^'3y �y Applicant -Z CLOTHES WASHER
NOTICE TO APPLICANT: If, after making th Certificate of ADDRESS
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL. NO.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. ,' WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO, PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER,
and Professions Code,and my license is in full farce and effect. 5 PER SYSTEM FINAL _ (p VALIDATION d
License Number Lic. Class DATE �� /��� V
FINAL Q
Contractor Date BY ` 0
V
❑ W
I am exempt under Sec. d
B.BP.C. for this reason w
Plan check fee D
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor"Li cense
Law for the following reason (Section 7031.5, Business and Address 1 6 7.7 A
Professions Code): City Tel. No. jf 0 0 0 0 0 5
InJ I, as owner of the property, will do the work and the '
structure is not intended or offered for sale (Section D ,2 ° ° 4 0 5 0
7044, Business and Professions Code). t
CONSTRUCTION LENDING AGENCY 0 0.0 Q 0,5 0 60
1 hereby affirm that there is a construction lending agency for 0 6 0 1._8 4
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the D
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbin J; and hereby
authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
e gnature ermittee Date