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HomeMy Public PortalAbout5635 CAMBURY AVE_Plumbing__ WORKERS COMPENSATION,DEQARATION 9 p - s hert�y W rin'that have acertrfmate cf consem to self m pA66�A PW14/87 T PY - PPLGC�►TGON FO�..�wiUi�B�G PER wie,or o cer"ficote of Workers'Compensation Insurance,;or a OF 817(REV a/86) - celtifiedcopythereof (Sec,3800 Lab C:) a `�• ' COUNTY,OF"LOS.ANGELES ` ..DEPT. OFPUBLICWORKS Policy.No Company l'�&J:C _ Ce tified copy,is hereby famished a ` _ t t' ' FOR APPLICANT TO FILL IN(PRINT OR'TYPE)' - BUILDING' -� Certified copy is filed with the.county bu' Ing ms'ecfion ADDRESS �j deportment..+ _ :NUMBER • Y..FIXTURE.OR ITEM (al 'FEE.' - u- f� „t LOCALITY l N f WATER CLOSET TOILET) 1Q� Date /!��._'�Applicant NEAREST..' - CERTIFICATE OF EXEMPTION FROM' 'WORKERS -J BATHJUB' cROSS ST. ' ,COMPENSATION INSURANCE1 O OWNER J SHOWER 14 (This settion'need snot be coinplafad if the'Jvork involved by-. - MAIL /" the pno ermit is for ohundred dollars (5100).or less.).- ; ,LAVATORY, - - '��• DO gODRE55*` ) y/ GJ/ ,7 IF I certify that m theperformooce of.the work for which this per- i SINK,- '- '-- ,: CITY TEL NO mit is issued 1,611 not employ any person-in any manner so - n©O )f as to become subject•to'the Workers Compensation Laws. DISHWASHER - aD CONTRACTOR t/s )' V/ / ✓t• �7 Dote-I '' 'Applicant -/ °� '- - - CLOTHES WASHER I NOTICE TO APPLICANT If, offer making this Certificate`of'Ex - - - Lim ADDRESS J.f:ty . ,yJ_ ��- SWIMMING POOL RECEPTOR emotion, youshoul8 become subject o the.W forth Co cornip CITY ii [moi TEC NO tl '''sation.pr6vlsoris.oflhe,Labor Code, yaumust forthwith tamp- .IAVJN SPRINKLER SYSTEM "rt `a„ lywith'such provisions or ih irpermit shallbe deemed.revdk STATE" - LIC: yF i -LICENSE NO. 9• L CLASS / ,• -. LICENSED CONTRACTORS DECLAR,ATION WATER HEATER DISTRIC NO, - - OCESSED BY GAS SYSTEM OUTLETS t}Q� ' hereby affirm that.lbm,licensed under provisions of Ghopter - , 9(commencing with Section 7000)of Division of the Business - OUTLETS OVER - - - 'p' and Professions Code, and my license.is'in full force and ef- 5 PER SYSTEM FINAL' VALIDATION S J� DATE O License Number 4 /� ri/tom Lic_Class `J _ ,.. p FINAL Cornmutor A"_12-ef/,j Date" � I BY / - O H I'am exempt under Sec. _ -- i/ W ... -. -B BP.C..for this reason `• e- 'N to _ Plan check fee D , Z. Daisi PLUMBING PERMIT ISSUING EEE $_ 't 'Signature - '- TOTAL-FEE. SINGLE FAMILY _ HOME OWNER-BUILDER DECLARATION Plan cl. applicant. I hereby affirm that I am exempt from thec _ 'Contractor's License Nome - _ - Low for the following'reason (Section 7031.5, Business and - QAC -T.i u ' Professions Code): Address3307 112.50- a ,I, as,owner of'the property, will•dothe work ct dcl 'City, .. Tel. No. T, structure is not Intended or offered.for ale(Section 7044, TEM � � � 1 I ` Busmess'ond Professions Code) r• ' . ' -.• - - ' _ cd TOTAL 11`?. - CONSTRUCTION LENDING AGENCY " i ,D - �• n'c Ihere6y affirm that there is construction lending agency for - CiHGG 11�.JO the performance oft,fhe work for which this permit is.issued - - • -C,HAN E• (Sec. 3097,'Civ: C:) - - _ - t . . . - Lender's Name ,0400-0001 - 10l 12/E9 ,. Lender's.Address620 1028 1 • AML certify that I have read this.application and state.thof:.the obovVinforloion'is correct. I agree to comply with all County ` D " Toon n Stat s,.regulahng..Plumbing, and'.hereby • - s - -. aut r e• ep sentativ sof this County to enter, upon the abov m do edtprop rty for ihspec{ion..purpos s. ' ,• SEE,REVERSE FOR EXPLANATORY LANGUAGE - - - • " Signature of.Permittee Ddfe. • {