HomeMy Public PortalAbout5632 CAMBURY AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION vcwssrA
I hereby affiem that I have a certificate of consent to self ceenlz-eol APPLICATION FOR PLUMBING PERMIT
insure, ora certificate of Workers'Compensation.Insurance,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) BUILDINGADDRESS i56'r/3 Z :N.t//
C4M f3UIZ ,
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM 0 FEE
department.
LOCALITY � . Cr1
. - r WATER CLOSET bU
Date Applicant NEAREST
BATHTUB - - CROSS ST. L/V�� OIdK
CERTIFICATE OF EXEMPT16N FROM WORKERS'
COMPENSATION INSURANCE SHOWER a0 OWNER
MAIL' }
(This section need not. be completed if the work involved LAVATORY - oc ADDRESS dS.4136ve a
by the permit is for one hundred dollars ($100) or less.) SINK -
3 CITY TEL.NO. U'
I certify that in the performance of the work for which this DISHWASHER
permit is issued, I shall not employ an CONTRACTOR '
p y y person in any manner (lL C 67l 0
so as to become subject.to [he or s' C mpensation Laws. CLOTHES.WASHEft ADDRESS
Date 10-13-31 Applicant ^!; SWIMMING POOLRECEPTOR n d
NOTICE TO APPLICANT: If, after making this Certificate of CITU r% - TEL. NO. t3-5;8 rA
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM -
STATE ,o LIC. Z
1 _
Compensation provisions of the Labor Code, you must forth- WATER HEATER LICENSE NO.Z3 '83 CLASS
with comply with such provisions or this permit shall be DISTRICT NO. - P OCESSEDBY
10
deemed revoked. GAS SYSTEM OUTLETS r>o
LICENSED CONTRACTORS DECLARATION - OUTLETS OVER cI)e,
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL
ness and Professions Code, and my license is in full force and DATE VALIDATION��z�-��
effect.
FINAL
License Numb Z3 9a� Lic. Class--�—> `S _J
BY
Contractor Date/0-/3-.51 U , C>,l
Q. 1 am exempt from the licensingrequirements as I am a Plan Check fee
licensed architect or a registered professional engineer .p-Z 2G_ t.•
acting in my professional capacity (Section 7051, Bus- PLUMBING PERMIT ISS LING FEES
iness and Professions Code). TOTAL FEE Z OC \
Lic.or Reg.No. _ Date L
check applicant
HOME OWNER-BUILDER DECLARATION e (t ,2 ZBez
I hereby affirm. that I am exempt from the Contractor's- ressL2 ZLicense Law for the following reason (Section.7031.5, Busi- 0,e4AJTel.No.7l�v -J�g 00 -
ness and Professions Code): .g 1 Jr 1.5 A.
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project _ # olo o e e'5
(Section 7044, Business and Professions Code). - - -
Z,o o2&O0
CONSTRUCTION.LENDING AGENCY
I hereby affirm that there is a construction lending agency o e.o 2a Q 05
for the performance of the work for which this permit is _
issued(Sec. 3097,Civ.C.). 101 3:-81
Lender's Name -
Lender's Address
I certify that I have read this application and statethatthe
above information is correct. I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the _
ab ed pro try for inspection purposes.
`o/3-8/
Signaturel5f Permittee Date ,