HomeMy Public PortalAbout5138 CAMELLIA AVE_Plumbing__ `"°�I Rs'c°r"P6"sATI°" Dano" APPLICATION FOR PLUMBING PERMIT
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I he4y affirm that ve a certificate of consent to self 20-0028 D 87
PW 6/
Insure, or a certificate of Workers' Compensation Insurance, 7BA687A
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORK&
policy No. Company
Certified copy is hereby furnithed
FOR APPLK'ANf TO FILL IN(PRINT OR TYPE) BUILDINf3��---•// (�
El Certified copy is filed with the county building Inspec- ADDM357B ,4IN9-'ZUXA t Jyc-
tion department. NUMBER FIXTURE OR REM Q PEE L�X_A.UTY � J��
Date Appllrant WATER CLOSET _ NEAREW
CERTIFICATE OF EXEMPfIQN FROM WORKERS' BATH TUB CRC35 ST. Zj#- �
COMPENSATION INSURANCE oyyt�
(This sectlin need rids be complitad If flat hark Jmrohr d byMAJL
e
the perm"Is for one hundred dollarr(11100)of less.) LAVATORY ADDRESS ,�t
I certify that In the performance of the work for which this
permit Is laked,1 shall not employ any person In any manner �i Te NO.so as to=e subject to the Worke Compensation DISHWASHER.
CONTRACTOR
Date lira {YOTHES WASHER
ADDRESS
NOTICE TO APPLI If, after makln Is Certtflkxrte of SWIMMING POOL RECEPTOR '
Exemption, you should become subj to the Worken' CITY TEL NO
Compensation provisions of thq Labor Code, you must forth- LAWN SRI WLER SYSTEM
with comply with such provisions or this permlt shall be STATE LIG
dtemed revoked. WATER HEATER �.
LICENSED CONTRACTORS DECLARATION DISTRICT NO. BY
I hereby affirm tlwt I am licensed underpp�ravWons of Chapter 9 OAS SYSTEM OUTLETS
(commeming with Section 7000) of Divlslon 3 of the Busmen OUTLETS OVER
and ProfesJTons Code,and my Ikense Is in full force-and efftct. S PER SYSTEM FINAL P VALIDATION �
DATE
LJcense Numbir Ilc. Class
FI
it
Contnxtor Date 0•
I am exempt under Sec.
B.BP.C. for this reason Plan check fe8
Date: Z
KUMBING PERMIT ISSUING FEE
Slgrpturw ; 0 �'
TOTAL FEE LV
SINGLE FAMILY
Ptpn check applicant
HOME OWNER-BUILDER DECLARATION Name
At-..
I ftereby affirm that I am exempt from the Contractor's License r
Law for the following reason (Section 7031.5, Bush" and Address . I
ProfeeslonsCode): City Tei. Na. `--
1
1, as wner of the property, wJtl do thq work and the - ��C
o
strucTure Is not Intended or offered for'sole (Section
704, BusJness and Professions Code). T' 34- 50 .
CONSTRUCTION LENDING AGENCY
1 hereby affirm*Wlhere Is a construction lending agency for
the performance of the work for which this permit I# Iwued C:]' k'; °T
(Sec, 3097, Civ. C.).
Lenders Name 0-,Y,-0031 9°
4!28!
V L'.
Lender's Addron i n.R
I certify that I•have read this application and state that the t AM u°5
above Informatlon Is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize repretentatives of this County to enter upon the
abov mentloned'property for I si5ectlon purposes. _EE REVERSE FOR EXPLANATORY LANGUAGE
0�
SI natur6 Permittee Dat