HomeMy Public PortalAbout4852 CAMELLIA AVE_Plumbing__ �'� •_,- 'WC dKERS'COMPENSATION DECLARATION t. APPLICATION FOR PLUMBIND PERMIT
firm y6
I henil afthat I have a certificate of consent to self 7pg7A uv nae PERMIT
insure,-or a cen 1`B!6t`e"of Workers' Compensation Insurance, CE 817(REV. 10/81)
or a c4tifiied.copy thereof (Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No_. Compann
y
❑ Certified copy is herebyjfu niched.
.,H t ;iii1. - FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Q
F] Certifi[d copy is filed with the county building inspec- ADDRESS r-•
tion department. -NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' ' BATH TUB O CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER rfj¢ �. A
(This section need not be completed if the work involved by ��ss rr /^ ,fir
the permit is for one hundred dollars ($100)or less.) LAVATORY y,7 'ADDRESS �( ✓ come UL .n
I certify that in the performance of the work for which this PM ;i,
permit is issued, I shall not employ any person in any manner SINK 06 CITY r�
'Grr�' TEL. NO. v
I-
so as to become subje t to the Wts'Comp so on L s. -
DISHWASHER CONTRACTOR
Date ��•� Applicant r CLOTHESWASHER /
NOTICE TO APPLICANT: If, after ma ng this Certificate of 'ADDRESS
Exemption, you should become subject to the Workers SWIMMING POOL RECEPTOR '
CITY TEL NO.
Compensation provisions of the Lobo! Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be ' STATE LIC.
deemed revoked. WATER HEATER 6 LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NQ. PROCESSED BY
I hereby affirm that I am licensed under provisions-of Chapter 9 GAS SYSTEM OUTLETS c /Oa
(commencing with Section 7000) of Division 3 of the Business• OUTLETS OVER
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL�J yrJ� VALIDATION
GV, CJIT a
license Number Lic. Class 0
FINA U.
Contractor Date BY
❑ 1 am exempt under Sec.
B.BP.C. for this reason
Plan check fee d
Date: PLUMBING PERMIT ISSUING FEE$ # $�i®':�'�.� Z
Signature
TOTAL FEE -4,7-4-049 -
e s40 50
Plan check applicant ♦ e e 4.Q 5'0,=
SINGLE FAMILY � ,
HOME OWNER-BUILDER DECLARATION• Name 7 2:1 8'8
1 hereby affirm that 1 am exempt from the Contractor's License Address
0
Law for the following reason (Section 7031.5, Business and
Professions Code): - City Tel. No.
ICJ.' 'I, as owner of the property, will do the work and the.
structure is not intended or offered for sale (Section
7044, Business and Professions Code). /
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued �1
(Sec. 3097, Civ. C.).
r ,
Lender's Name
Lender's Address
I certify that I FoVe.read this application and state that the D '
above information is correct, I agree to comply with all County
ordinances and Slate laws regulating Plumbing, and hereby
authorize representativ s of this County to enter upon the
abov mentioned pro e ty for ect' n purposes.
�' �e SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature`offermittee Dote