HomeMy Public PortalAbout6029-6033 CAMELLIA AVE_Plumbing__ WORKERRS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby.afflrm that I have a cerflflcate of consent to self 29-0026 DPW 9/87
Insure, or a certtflcate�df WorkersCom tion Insurance, 76A667A
or a cetti t eof (Sec. 300 a C.) 12, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy N Mpon (�,O
Certified copy Is hereby furnished. r
FOR APPUCAtIT TO RLL IN(PRINT OR TYPE) BUILD NC' �� GL A
Certified copy Is filed with the county building Inspec,
tl n nt. NUMBER FIXTURE OR ITEM FEE
WATER CLOSET �- Loc�tTYl���
Date Appll4anti NEAREST
Ir CERTIFCATE OF EXMM MQN FROM WORKERS' BATH TUB � � CROSS�
COMPENSATION INSURANCE IativFR OWNER
sa
(This section need not be completed N the work hwohred by MA,La
the permit is for one hundred doltars (;100)or toes.) LAVATORY Q ADDRESS
Q
I certify tbat In the performance of the work for which this l
permit is Issued, I shall not employ arty pe non In any mgnner / SINK �CJ/
was to become subject to the Worker Gompenidtion Laws.
Date Applicant CLOTHES WpS.I-ER
NOTICE TO APPLICANT: If, after making this Certlflcatd of ADDRESS �� ��'P t�s'Q
Exemption, you should become -subject to the.,Workers' SWVMNNG POOL CI Y�G TEL
Compensation prowl;Ions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such proWslons or this permit shall be STATEp� UC.
deemed revoked. WATER HEATER —, NO ZzeO CLASS
LICENSED CONTRACTORS DECLARATION NO, Y
I herby affirm that I am Ilagnied under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commwxlrp with Sectlon 7000) of DIWOon 3 of the BLWnep CUTLETS OVER
and Ptoftnlons Code,and my license b in full f a effect. 3 PER SYSTEW r FINAL
�f pDATEvy ��DAnoN rt
License Numb.?/ Po � Llc Class
Confi aotrn
BY (`X,
I am exempt undee Sec. D
B.BP.C_ for this reason Plan chetk fee
Date. plov.
PLUMBING PERMIT ISSUING FET;Slpnaturo_
TOTAL fEE O
SINGLE FAMILY Pk n check applicant
HOME OWNER-BUILD+<R Dl CL TIQN Nome
I heFeby affirm that 1 am exempt from the Conft-cK silcerae ACCT.i
Law for the followin reason (Section 7031.5, Buslnpn and AddTdu
Profwlortt Code): City Tel, No. 33D7 118.50
I, as owner of the property, will do the work and the. 1 ITEM
structure Is not Inten¢bd or offered for sale (Section , TOTAL I IS- 50
7044, Businees and Professlons Code).
CONSTRUCTION LF-NDING AGENCY GECK 118.50
1 herby affirm th¢t there Is g construction lending agency for .
the performance of the work for which this permit is Issued avow
OD
(Set. 3097, Civ. C.).
Lender's Name 1000ID�JI l 1:•10/47
Lenders AddresF 7596 1 MINK,
I certify that I have read this appllcataon and state that the
above Infohnafion Is correct. I agree to tomply.with all County
ordinances and State laws regulating Plumbing, and hereby
authorize repre1entatives of this County to enter upon the
o e mentlooperty for Inspection P4rposes. SEE ltt/ERSE FOR EXPLANATORY LANGUAGE
//.,6 P'9
Signature of PermitteeDate