HomeMy Public PortalAbout6033 CAMELLIA AVE_Plumbing__ vKORKERS'.COnnPEr,SATICxN DcLARATION APPLICATION FOR PLUMBING PERMIT
I herbby.affirm that I have a certificate of consent to self 20-0028 DPW 8/87
Insure, or a certlfikbte.df Workeri Compensation Insurance, 7dA887A
ora certifleclcopy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
olcy No994965 CompanyRep, Indemni ty
Certified copy Is hereby furnished.
❑ FOR APPUCAxi TO FILL IN(PRINT OR TYPE) BUILDING
ADDRESS 6029=603'q 'Camq-J}ig, �
Certified copy Is filed with 10,a cou ry building Inspec- LIMBER FDCTUREOR ITE, Q I$
tion department. LOCALITY le City
Date 6/2490 Apply WATERCLOSET
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST,
COMPENSATION INSURANCE — SrIOWER OWtt92
(fhb section need not be completed If the work Involved by
the pwmlt is for one hundred dollars(=100)or less.)e ) LAVATORY �Q DRESS
I certify that In the performance pf the work for which this r
permit Is Issued, I shall not employ any Person In any manner SINK CITY TEL. NO' 2RO—Al
to as to become subject to the Workers Compensation Laws. —�
DISHIWASHHt — ��`raIl}{ MaI"r017e and SOILS r 'QAC.
Dote ATllcant CLOTHWASHER _
NOTICE TO APPLICIA T: If, after making this Certificate of ADDRESS 9860 Lower Azusa Rd,
Exemption, you should become subject to the Workers' SWIMMING POOL ROTOR C]iY TEL
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM El Monte 44-2548
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WAS HEATER LKINSE NO.nU 397884 CASs C/36
uC ENSED CONTRACTORS DECLARATION DiSTR BY
I hereby affirm that I am I lcenied under provisioro of Chapter 9 GAS SYSTEM OUTLETS _o /`l 5(
(commencing wttFr Sectlon 7000) of Dlvfslon 3 of tfie Business OUTLETS OVER lJ(J
and Profe4slo4nt Code,and my Iknrne Is in full force and effect. 5 PER SYSTEM RNAL V [MATION
6 e ss �- DATE
License Number 397884 Ilk. Clas3C 36
Controctot art � Do 0—
�' NAL
❑ I am exempt under Sec
B.dP.C, for this reason Plan check fee
Date: PLUMBING PERMIT ISSUING FEE; � z
S I q rwtu rw
TOTAL FIFE SO
Plan check applicant g
SINGLE FAMILY
HOME OWNER-BUILDER.DEC].ARATICNJ Name ACCT.4
I hereby affirm th¢t I am exempt from the ContraCTOr*UkOnse JJV7 118.
Law for the following reason (Section 7031.5, Business and Address
50
professions Cas e): City Tel. No. 1 I1
❑ I, as owner of the property, wil[do the work and the TOTAL 118.50
structure Is not Intended or offered fo{ sale (Section CFECM► 11$■
7044, Business and Professions Code�
CONSTRUCTION LENDING AGENCY .00
I hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit Is Issued
(Sec. 3097, Cly. C.).
00IM-OW 1 12/18/89
Lender's Name AM10:52
7 ,a G 7597 1
Lender's Address
I certify that I have 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 rgpre1entatives of this County to enter upon the
olpove-rnsn pned property for Inspection purposes.
SEE REVERSE FOR EXPLANATORY LAN6UAGE
Signature of Permittee Date