HomeMy Public PortalAbout6030 CAMELLIA AVE_Plumbing__ . . .+,A:WORKERS'COMPENSATION DECARAnON APPLICATION FOR PLUMBING PERMIT
'J hereby affirm that I have a cert)flcate of consent to self 2D-0026 DPW 6/87
Insure, or a certtfioate of Workers' Compensation Insurance, 76A687A
or a certified copy thereof{Sec. 3800, La . C•) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No,&&:92 Compan Aq _
fL-J edified copy Is hereby furnished. &��– ��-
FOR APPL}CAW TO FI IL IN(PRINT OR TYPE) BUILDING
LXff CADDRESSertified ropy Is filed with the county building Inapec- NUMBER FUTURE OR ITER O FEE
tion departmen}t� LOCALITY
Date lirant /v ✓/ WATERaQSET 44' tE,s,�
CERTIFICATE OF EXEMPTION FROM WOROZZS' BATH TUB CRO55
COMPENSATION INSURANCE SHOWER OWNER
(Vols seerion meed not be contplefed if the work Irtvc4v by MAIL
the permit Is for one hundred dollar(S 180)or Feet.) LAVATORY ADDRESS
I certify that In the performance of the work for which this 7�2
permit Is Issued, I shall not employ any person In any manner SJNk CITY TEINO..VJ,6
so as to become subject to the Workers Cgmpgnsatlon Lpws
DO-[WASHiER CONTRACTOR 622-5,
Date Appircant CL01}ES WASHER
NOTK:E TO APPLICANT: If, after making thls Certificate of A
Exemption, you +hould become subject to the Workers' SWIMMING POOL RENTOR � TEL. NO.
Cotrlpensation provisions of the Labor Coot, you must forth, LAWN SPRINKLER SYSTEM 61
with comply with such provisions or this permit shall be
deemed revoked. WATER FEATER STATE G
uc�RSE No. SSS
LICENSED CONTRACTORS DECLAPATIQN / D1STRLCT NO. PROCESSED BY
I herby affirm-that i am licensed under provisions of Chapter 9 SYSTEM OUTLETS
(commenting with Sbctlon 7000) of Dlvlslon 3 of thr Business OUTLETS OVER Q
and Profeesionw Code,and my license is In full force and effect. S PER SYSTEM FINAL VALIDATION �
LIcenee Numbtr c. Class..C-22G `� DATE
FINAL
Contractor "TJj4a's J r .Date CCC����••'
BY
r
Q1 am exempt under Sec.
B.BP.C. for this reason
Plan Check fee
Dar.: PLUMBING PEIZMrT ISSUING FEE; o?(/AS' —
Signature
TOTAL'FEE O
SINGLE FAM14Y
Pion check appllcant
_� •
HOME OWNER-BUILDER DECI,ARATK)N Name
I hereby afftrm that I am exempt from the Contractors License ^ddre:a '•��.i
Law for the following reason (Section 7031.5, Business and
((Professlons Code): City Tel. No. 3311 243•(313.
as oWnsir of the property, will do the work and the 1 11E110,
sttuelure Is not Intended or offered for sale (Sectlon
7044, busloess and Professions Code). TOTAL 243-'00
CONSTRUCTION LENDING AGENCY (�E,:K
I hereby affirm that there Is a construction lending agency for
the performance of the work fpr whlcb this permit is Issued
(Sec. 3097, Ov. C.).
Lender's Name
Lenders Addren131 AN 10:11
I certify that I have read this application and state that the ►
above Informgtlon Is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize repre1enfatives of this County to enter upon the
above-mentloned property for In;pectlon purposes.
SEE REVER;E FOR EXPLANATORY LANGUAGE
Signa re of Perm ee Date