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Home My Public Portal About5238 CAMELLIA AVE_Plumbing__ r WORKERS'COMPUN TION DSCLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a cerdflcate of consent to self 7&A-667A Insure, or o certificate,of Workers'Compeasatlon Insurance, CF 817(REV. 10/81) ari f,I&VyP7117%( ,3�e_o°�` " e / COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy Nlfo.—TCompany Poll Certtfiedcbpy Is hereby-fvmished. FOR APPLC1tdT TO FILL IN(PR)NTCNt TYPE) I3UII,DING� � Certified copy Ir Vied with the county bulldIW Inapec- AD15RESS }� 141 � tloD department. f NUM$ER FXMkE OR rrEM Q FFf Dato- ApR114bnr .J�� WATER CLOSET C ERTIFIGAT5 OF DCFMFION FROM WORKERS' BATH TUB COMPENSATION INSURANCE SWOWER OWNER (This oecMon netad not be complattetd If that work Imrolwd by that pw•mlt is for one bwndtvd dollars J$100)or Is".) LAVATORY AppLRf55 , p j I certify that In the performance of the work for which this permit Is issued; 1 shell not employ any person In any rnanner. SINK CITY ` a" TEL NO. so as to become*ublect to the Workers"Compensation Laws. DISF[WASHER / CONTRACTOR � �� a d k Date_ fors l i ca n t C tOTHES WASH ER * NOTICE TO APPLICANT: If, after making this Certificate of A O�/Z:, —"O �t ��'' t�4`� Lemptlon, you should betome svbj&d to the Workers' SING POQL RECEFTOR "J C7T1 Ifr� TEL NO. r6 7' CofiF comply with such of The Labor Cede, you must#nilly LAWNSPRINnER SYSTEM wltt� comply with suth plovlslonf or this,perrrllt.sha4l be - STATE � � � yLIC.aSS deemed revoked. WATER HEATER CBJSE NO. LICI=NSED C09RAC;TOIZS DECLARATION D NO, EY IherebyafHrrh that I am Ilcen3ed Under provblons of Chapter 9 GASSYSTtM1 fir$ r (commencing with Sbctlon 7000) of DIvislon 3 of the Bushels OUTLETS OVER r >- ii and RrofoWorm Code,arrd my license is In full-force and d PER SYSTEM FINAL VALIDATION V / DAT '� License Number lc- Crass �� '' v cc FI 0 Contractor Dote BY Ci W a tam exempt udder Seo f ?3 N Jj Z B.SP.C. for this reason Plan check feel Date: PLUMBING MERMIT ISSUING FIBS Slgnpture TOTAL FEE 13 Plan rhed{pppnc�nt SINGLE FAMILY • HOME O1A+N R-BUILDER DECLARATION Name I kweby affirm that I am exempt from the Contractors License Address _.7 7� � ALaw for the following reason {Section 7091.5, Business and Profes}lom Code): City Tel. No. I, as owner 6f the property, will do the work dnd The structure Is not Intended or offered for sale (Section , .2 o o 3050 7044, Business and Professions Code). CQNSTRUCTFON LENDING AGENCY ° 7 •S 0 is J hereby-offltm that There rt a construction lendrdg agency for J 22 1 —0- 3 the performance of the work for which This permit it Issued (Set. 3097, Civ. C.), Lender's Name ti [ender's A4&esx 1 certify that I hove read Is cipplitation and state that the , above inforrng06n Is . I ogrge to comply with all County prdlnant layn rgguloting Plumbing, and hereby out ntatl of this County to enter upon the abov - tion pro for Inspection pprposes- SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of rmltt" 0018 a WORKERS'COMPENSATION DECLARATION 20-0026 DPW VW APPLICATION FOR PLUMBING PERMIT qI h rbb* affirm that I have a certificate of consent to self In- 7~Awr or d�rtlflcate of Workers'Compensation Insurance,or a ifled copy thereof (Sec. 3800, Lab. C.) 4 COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company Certified copy Is hereby furnished. FOR APPLICANT TO RLL IN(PRINT OR TYPE) BUILDING Certified copy Is filed with the county bullding inspection ADDRESS department. NUMBER RXTURE OR ITEM REE LOCALITY Date Applicant WATER CLOSET(TOtLIET) NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE �y„� awNl (This section need not be completed If the vrork Invo#ved by MAIL the permit Is for one hundred dollars ($100)or leas.) LAVATORY ADDRESS I certify that In the performance of the work for which this per- Crry C e TEI NO.iffif 4W2 mit Is Issued, I shall not employ any person In any manner so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Date. Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certtflcate of Ex- SWIMM1NG POOL RECETOR emptlon,you should become subject to the Work"'Compen- CRY Ta.NO. action provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok- STATE UC ed. rWATER HEATER 15" LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION � DISTRICT NO. PRBY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS �p 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER fact FI Professions Code, and my license is In full force and of- 5 PER SYSTEM FINAL VALIDATION HOSE BIB >_�—2 `R Licerse Number Llc. Class FINAL U Contractor Date BY iy O ❑ I am exempt under Sec. t W B.BP.C. for this reason Plan check fee , Date: PLUMBING PERMIT ISSUING FEE$ `L Signature TOTAL FEE SINGLE.FAMILY - HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name A�•� i .c Law for the following reason (Section 7031.5, Business and Professions Code): Address tl•� 1, as owner of the property,ffwill do the work and the City Tel. No. 1 ITEIS structure Is not Intended or oered for sale(Section 70.a, TOTAL 41 _ 8z Business and Professions Code). C#E(:V. . CONSTRUCTION LENDING AGENCY I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit Is Issued (Sec. 3097, Civ. C.). �.q'Qfl1 Lender's Name 4910 1 AM IS"c Lenders Address I certify that I have read this appJlcatlon and state that the , above Information Is correct. 1 agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize epresentatives of this County to enter upon the abovo-m Honed pr rty f In Ion purposes. , SEE REVERSE FOR EXPLANATORY LANGUAGE Signets a of Perm it. Date