HomeMy Public PortalAbout5008 CAMELLIA AVE_Plumbing__ 61ORKER that I have a: ION DECLARATION Ca 617^ APPLICATION FOR PLUMBING PERMIT
1 hereb`(�firm that I have a certificate of consent to self ce aro Iz-eol
insure, or a certificate of Workers'Compensation Insurance,or
a Certifie,411cnpy thereof(Sec. 3800,Lab.TC.)
�379D3-7f [Y4i � � COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS J t�Gr
Certified copy is filed with the county building inspection
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NUMBER FIXTURE OR ITEM • FEE V 0
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d Part / .r x'�L� LOCALITY '
Date Applicant/�'1✓!� / L/ WATER CLOSET ®d 'Q /� -
�lL(NG P/NB� NEAREST � �4e���
BATH TUB CROSS ST. ;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER j po OWNER gZletk)p
MAIL
(This section need not be completed if the work involved 1LAVATORY 3 00 ADDRESS O00p
by the permit is for one hundred dollus ($100) or less.) SINK �,r
3 CITY l' @[ r TEL. NO.ZP7�o16 0
I certify that in the performance of the work for which this DISHWASHER 3U
permit is issued, I shall not employ any person in any manner CONTRACTOR /A? �/ !1(
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER 0
ADDRESS 'eI N Z /7 O
Date Applicant SWIMMING POOL RECEPTOR A' V
NOTICE TO APPLICANT: If, after making this Certificate of CITY �5'A o _N�j TEL.NO20 0' tp
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE 2 LIC. / y
Compensation provisions of the Labor Code, you must forth- / WATER HEATER 2 ear LICENSE NO. 43 g�� CLASS a 3l0S Z
with comply with such provisions or this permit shall be J
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. PR ESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER 0(I
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM V
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL ))
ness and Professions Code, and my license is in full force and DATE VALIDATION S�b�-��
effect. CO-
License No mbar) t/i[ ' 7 Lie. Class 36 _ BY
AL -'
ContractorL (�a Date
Flam exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ Z BB
acting in my professional capacity (Section 7051, Bus- ^
iness and Professions Code). TOTAL FEE 2S dGY
Lie.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Address
License Law for the following reason (Section 7031.5, Busi- City Tel. No.
ness and Professions Code):
1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project
(Section 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency 2 rJ 9.`l A
for the performance of the work for which this permit is
issued (Sec. 3097,Civ.C.).
Lender's Name a - a a e 5
Lender's Address 2 c - 25M
I certify that I have read this application and state that the o 0 0 25 0 0
above information is correct.I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby I G1 4-80
ho ' esentatives of this County to enter upon the
abo -mensne roper y ffeVnsp ton purposes.
gignature of Permittee Date