HomeMy Public PortalAbout4913 CAMELLIA AVE_Plumbing__ WORKERS'COMPENSADECLARATION
I hereby affirm that I hove a certificate of consent to self 76A667A APPLICATION
FOR PLUMBING mERMIT
insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
ora ertified co thereof (Sec. 3800, lob. C.) COUNTY OF LOS ANGELES `�' �x BUILDING AND SAFETY
OicyNo. i5� CPA Aetna Casualty & Surety
/ l
Policy No. Company y
Certified copy is hereby furnished.
® FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building nspec- ADDRESS 4913 Camelia Avenue
tion deportment. SERVAMATIC SOLAR NUMBER FIXTURE OR ITEM ret FEE
LOCALITY Temple City::
Date 9/2/83 Applicant SYSTEMS, INC. WATER CLOSET - NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER ISHIKAWA RUSSELL & CORRINE
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
SAME
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO. 285-3026
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR SERVAMATIC SOLAR SYSTEMS
Dale Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of - 20290 E. Carrey Road
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY Walnut, 91789 TEL. NO. 595-7433
with comply with such provisions or this permit shall be (AWN SPRINKLER SYSTEM
deemed revoked. 1 WATER HEATER solar 20 00 STATE ESE NO. 390645 CLASS C36 SC44
LICENSED CONTRACTORS DECLARATION DISTRICT NO. OCESSED BK
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
{and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION O
sl License Number 390645 Lk. Class C36 SC44 U
DATE �r �¢ '
SERVAMATIC SOLAR SYSTEMS 9/2/83 FINAL O
Contractor Date U
❑ 1 am exempt under Sec. �� d
N
B.&P.C. for this reason Z'
Plan check fee D
Dote: PLUMBING PERMIT ISSUING FEE$ 10 50 _ ;F 5 1,5.9 A
Signature # o e o a o E
TOTAL FEE 30 50 2 ^ 0 3 0. 5 0
Plan check applicant
SINGLE FAMILY o e o 3'a 5 0 XQ
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that 1 am exempt from the Contractor's License 0 9 1 3—8 3
Low for the following reason (Section 7031.5, Business and Address
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section D
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY -
I hereby affirm that there is a construction lendinq�agency for -
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name NONE
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 Slate laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
ve-mentioned prop y for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
9/2/83
Signature of Pe m tee. Date