HomeMy Public PortalAbout5208 CAMELLIA AVE_Plumbing__ affirm FKr c°�"SST'°" °�",�Tent p..�DPW x,� - APPLICATION FOR PLUMBING PERMIT
Ll hgrsby+affirm that I have a celtlflcate of consent to self In.- 76Ab67A
.sure,or a cerilflcute of Workers'Compensatlon Insurance,or a l
certtffed dopy thereof (Sec. 3800, Lab. C.)
COUNTY-OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
❑ Certified copy Is hereby fumished.
FOR APPLK'.4NT TO.FILL IN(PRINT OR TYPE ZD
Certified copy Is filed with the county building Inspection NUMBER
department. FDc71JRE ITEMLOCALITY
wATEk CLOSET froILET)
Dote Applicant NEAREST � �BATH TUB CROSS ST.
v
CERTIFICATE OF EXEMPTION FROM WORKERS' Z
COMPENSATION INSURANCE Si-t01MER OWtFR
(This sectlon need not b�Sompleted If the work hrvolved by MAIL f .
the permit Is for one hundred dollars(;100)or lees.) LAVATORY � y wl App
I certify that In the performance of the work for which this per- f SINK CITY. TEL l
mlf lased, I aha l not employ any person In p anon so -
to become subject to the Workers Com on Law}. DIS"ASHER
CONTRACTOR
Darn Applicant CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANt: If, aft eking this tate of Ex- SWIMMING POOL RECEPTOR
eMptlon,you should become subject to the:Workers'Compen- CITY TEL NO.
satlon provisions of the Labord
Coe,you must forthwith com((rr LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be doomed revok- STATE LiC
ed. WATER HEATER Q -UCENSE NO.
410ENSEDCONTRACTORS DECLARATION O DISMK:T NO. BY
I hereby affirm that I am licensed under provlslons of Chapter GAS SYSTEM
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license Is.In full force and of- 5 PER SYSTEM n FI ATION f4�
fect. Z HOSE 131BL O DA G7
License Number LIc..Clau
FINAL
Contractor Date BY
❑ I am exempt under Sec.
B.&P.C. for this reason PIQn chCCk fee ,
Date: PLUMBING PERMIT ISSUING FEE$
Signature TOTAL FEE 3 - 20
SINGLE FAM14Y plan check applicant
HOME OWNER-BUILDER DECLARATION r}
I hereby affirm that I am exempt from the Contractors License Name
Law for the following reason (Section 7031.5, Business and K.GT j
■T
Professions Code): Address
3M.20
Kalli as owner of the property, will do the work and the City Tel. No.
structure Is net Intended or offered for sale(STT[�iL+ection 7044, x 1 I 1I M
Business and Professions Code). ►
TOTAL. 333-20
CONSTRUCTION LENDING AGEN(,-:Y
QECK M.102
I hereby affirm that there Is a construdlon lending agency for
the performance of fhq work for which this permit Is Issued UWE .00
(Sec. 3097, Cl v. C.}.
Lenders Name 01310D—M1 1/29/96
Lenders Address 4514 1 AM10:38
I certify that I have read this application and state that.the ,
above InformatiQn Is torr . r agree to comply with all County
ordinances and State regulating Plumbing, and hereby
authorize rep atives of this County to enter upon the
/boye:mantI perry for I pectlon purposes.
a! SEE REVERSE FOR EXPLANATORY LANGUAGE
Slgpdlure of Parmltt Date: