HomeMy Public PortalAbout6025 CAMELLIA AVE_Plumbing__ WORKERS'COMPENSATION DlC1.ARAT1oN APPLICATION FOR PLUMBING PERMIT
I b rbb 'crWrm that I hays a certificate of consent to self 20.0026 DPW 6/87
Insure, or a certificate-of Workers` Compensation Irnurgncs, 76AWA (I JI
or a certlfl hereyf (Sec. b. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy Nc -.%r � Comps
❑ Certified copy is hereby furnished.
POR APPLIGNr TO FILL IN(PRINT OR rYa+=) BUILDING
Certified copy Is filed with the county building Inspec- ADDRESS O -r
n epartm nt. NUMBER R?(TURE OR ITEM O FEE
LOCALrTY
Dots �Appll�ant J�''���"�_J
WATER CLOSET
BATH TUB Q CROSS 'ST.
KER
CERTIFICATE OF D(EMFPQN FROM WOR $' w /
COMPe4SATION INSURANCE SHOWER Owt�t /5/
(This section need not be corrtpleted If the work Involved by MAIL
the pwmtt Is for one hundred do0ors($100)or Fess.) LAVATORY OD ADpRgt D l� ' Q
I certify that In the performance of the work for which this �'n
permit Is Issued, I shall not employ any person In any manner SINK er CITY �7 1'Y TE � ]JY
to as to become subject to the Worker Compensation Lava. DLSFIWASHER p O
ODiJTRAC-r
Date AT,rlicant CLOTHES WASHER ADDRESS
ftO r/
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING PQOL RECEPTOR � �r^G � G TEL
Compensation provisions of the Labor Code, you must forth- LAWN SPRR•AQER SYSTEM G
with compty with such provisions or this permlt shall be STATE LIG
deemed revoked. WATER HEATER Q bCENSE NO. CLASS
fg
LICENSED CONTRACTORS DECLAPAT10N � BY
I hereby arm that I am licensed under provisions of Chapter 9 OltiS SYSTEM OUTLETS
affirm Oa
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license Is In full force a effect. s PER SYSTEM FINAL
QZe�'! 31j VALIDATIQN
License Num
7' ilk. Class ��
as NAL
Cohtrocto �'�"�' Dat,-4-Dat,-4- 4/-Y' BY; a
❑ 1 am exempt under Sec.
r B.RP.C. for this reason
Plan check fee
Date. PLUMBING PERMIT ISSUING FEE ( —`
Signature
TOTAL FEE V
SINGLE FAMILY Plan check applicant 5
HOME OWNER-BUILDER DECiAPAT10N Name ACCT.T
I herby affirm that I am exempt from the Contractors License
Law for the following reason (Section 7031.5, Business and Address 3307 118.50
Professions Code): City Tel. No.
❑ 1
I, as owner of the property, will do the work and the
structure isnot Intended or offered for sale (Section , _ �AL 118.50
70", Business and Professions Coded
CONSTRUCTION LENDING AGENCY DECK 11$.50
1 hereby affirm that there Is a construction lending agency for (UWE .00
the performance of the work for which this permit Is Issued
(Sec 3097, Clv. C). �yyy • I01yy ry`
LendO
Lender's Name 0DQ- 1 1 J 181 rV
Lenders Address 7599 1 AM 10:53
1 certify that I have read this application and state that the ►
above Information Is correct. I agree to comply with all Caunty
ordinances and State laws regulating Plumbing, and hereby
authorize reprelentatives of this County to enter upon the
qmentioned'property for Inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date