HomeMy Public PortalAbout5144 CAMELLIA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION 2aDM6DPW4/&7 APPLICATION FOR PLUMBING PERMIT n
I hereby, dfflrm snot I have a certificate of consent to self In- 76A667A I
sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) lul
certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
❑ ;Certifled copy Is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
0 Certifled copy Is filed wqh the county building Inspection ADDRESS
department. NUMBER FIXTURE OR ITEM 8 FEE
LOCALITY
WATER CLOSET(TOILET)
7pm r)
Date Applicant NEST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB ✓i CROSS ST'
COMPENSATION INSURANCE SHOWER OWNER
(This sectlon need not be completpd if th♦work Ihvolwd by
the pormit Is for one hundrsld dollars (=100)or I*".) LAVATORY ,J AMA1pDRL ESS
I certify that In the performance of the work for wHich this per-
mit Is Issued, I shall not employ any person In any manner so CITY TEL
as to become subject to the Workers'Compensation Laws. JISHWASFIER
CONTRACTOR
Date Appllccint CLOTHES WASHER �
NOTICE TO APPLICANT: If, after making this Cerflflcote of Ex- SWIMWNG ADpRESS
emption,you sh6uld become sublect to the Workers Cpmpen- POOL RECEPTOR
Code, CITY TEL NO.
sation provisions of the Labor C e,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly.wlth such provisions or this permit shall be-deemed revok- STATE LIC
ed. WATER HEATER LICENSE NO. CLASS
LICENSED-CONTRACTORS DECLARATION DISTRICT NO. PROCVSSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS A�
9(commencing with Sectlon 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my Hcense Is In full force and ef- 5 PER SYSTEM FINAL. VALIDATION >_
fact. DATE d
License Number LIc. Class T- O
U
FI
cc
Contractor Date BY �O.
I am exempt under Sec. W
B.BP.C. for this reason Plan check fee
Date' PLUMBING PERMIT ISSUING FEE$
Signature TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check appllcant
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Sectlon 7031.5, Business and AULT
Profeulons Code): Address
7 ?8■XII
asown-of of the property, will'do the work and the city Tel. No.
structure is not Intended or offered for sale(Sactlb.n 70.4, 1 ITE*
Business and Professions Code). T&TFL 28- 00
CONSTRUCTION LENDING AGENCY
C�iEa
I hereby afflrm that there Is a cohstruction lending ogee y for
the performance of the work for which this permit Is Issued � 1� ■`�I
(Sec. 3097, Civ. C.).
.Lender's Name M-OW1 1f21.3/{]1
Lender's Address J14V 1 AM 10:17
I certify that I have read this application and state that the 011111'.above Information Is correct. I agree to comply wlth all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of thli County to enter upon the
a entloned pro rtyr Inspection pu ea.
SEE REVERSE FOR EXPLANATORY LANGUAGE
LI
Signature of Permittee Date