HomeMy Public PortalAbout6027 CAMELLIA AVE_Plumbing__ VJORKER'S'COMPENSATIO-N DEC °PAT'°N APPLICATION FOR PLUMBING PERMIT
I hereby,affirm that I have a certificate of consent to self 20-0026 DPW 6/87
Insure, or a Fertificate.df Workers' Compensation Insurance, 76A667A IL JI
orb certl o then (Sec. 3800, . C.)� COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy compan z
Certified copy Is hereby fumished.
FOR APPLICANT TO FLU_IN(PRINT OR TYPE) BUILDING
Certified copy Is filed with the county building Inspec-
n epartme it. NLIMBHt FUCTURE OR ITEM 0 FEE LOCALITY
WER ev,
Date D AppliSnnt4k' WATER CLOSET NEAREST
CERTIFICATE OF EXEMPT10N FROM WORKERS' BATH TUB CROSS
COMPa4SAT10N INSURANCE OWN�t
(This secllon need not be completed if the vrrgrk hmAved by MAIL
the pemit Fs for one hundred dollars (:100)or lees.) LAVATORY Q ADDRESS
I certlfy that In the performance of the work for which this
permlt Is Issued, I shall not employ any Person In any manner SINX r,11 Q
to as to become subject to the Workers Compensation Laws. DtSFfWA51ER
r
Date Arr, licant aoTHES WASHER
NOTICE TO APPLICANT: If, after making this Certlflcate of I[�
Exemption, you should become subject to the Worker' ' tNG POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM 7
with comply with such provisions or this permit shall be STATE UC
deemed revoked. WATER HEATER Lciam NO. CLAW
LICENSED CONTRACTORS DECLARATIONO15SYSTFJH S ffrRtCZNq _ BY
I hereby affIrrrrthat I am IIce rtsgd under provisions of Chapter 9 /V�f(��
(commencing with Sectlon 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is In full foc�andvffecl. 3 PER SYSTEM FINAL AUDATION
DATE
License Nu ben Lic. Class
tdoz FINAL
Contra. Date-- 7 0 s l3Y a
❑ I am exempt under Sec.
B.BP.C. for this reason Plan check fee
Date: D
PLUMBING PERMIT ISSUING FEE_
SIgncrture
TOTAL FEE d
SINGLE FAMILY Plan check appll4ant 5
HOME OWNER-BUILDER DECLARATION Namei
F�:GT.T
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.3, Business and Address �7 iii■�{l
Professions Cade): city Tel. No.
❑ I, as owner of the property, will do the work and the
strudture Is not Intended or offered for sale (Section , TOTAL 118 w 50
7044, Business and Prafesslons Code).
CONSTRUCTION LENDING AGENCY 0-ECK 1108.50
1 hereby affirm that there Is a construction lending agency for .0I
the performance of the work for which this permit Is Issued
(Sec. 3097, 0v. C.
Lendees Name 00O& 1 12/18/39
f 18/39
Lendees Address 76M 1 AM10=53
I certify that I hove read this application and state that the ►
above Information Is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize repre1entatives of this County to enter upon the
cybove-me toned property for Inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGESignature of Permittee Dale