HomeMy Public PortalAbout6035 CAMELLIA AVE_Plumbing__ V GRKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I herbby,a{flrm that I have'a certificate of consent to self 20-DD26 DPW-8/87
Insuri, or a Gertiflcate,df WorkerC Compensation Insurance, 76A6e7A
orb cwltfied copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT, OF PUBLICWORKS
-Policy No.994965 CompanyRepubliC Indemnity 5._ !\-
Certified copy Is hereby furnished.
❑ FOR APPLICANT TO RLL IN(PRINT OR TYPE) BUILDING
6029-60 3 Cal-Q4lia. r
Certified copy Is filed with he coup bulldlnq Irxpec-
Harldepartment. NUMBER FD(TUREORREM Q LOCALITY le Ci
Date Fi24C40 App ll�a WATER CLOSET — NEAREST
CERTIFICATE OF E(FMPTKDN FROM WORKERS' BATH IUB Ot055
COMPENSATION INSURANCE SHOWN OwNfl D. Co>;1stxuGtion
ls sectlon need not be eomplefed If the work Involved by
cX11
permli Ine Is for ohundred dollars ($100)or lees.) LAVATORAppyY O •]9
1 certify that Irl the performance of the work for which this
permit Is Issued, I shall not employ any Person In any mariner SINK CA1 TEL NO
so as to become subject to the Worker* Compensation Laws. DL&HWA5FER
Date A—llcant CLOTHES WASHERADO
NOTICE TO APPLICANT: If, after maklnq this Certificate of SWIMMING
Exemption, you should become subject to the Workers' POOL{ iOR
Compensation proylslons of the Labor Code, you mutt forth crry TE1
with -comply with such provisions or this permit shall be LAWN$PRINIQER STATE UG
deemed revdked. WATER HEATER LKINSENO. CUSS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. moamm BY
I hereby affirm-ffiat I am Ilcenied under provislors of Chapter 9 GAS SYST�M QTS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Rrofesslons Code,and my Ilcense Is to fulrforce and effect. 5 PER SYSTEM' FINAL ALIDA710114
Llcerse Numb*r-g7RAd It c. Ckm G1126 DATE
�_ ATE.
Contractor Haman'- Date-?/.31 — L
Z
I am exempt under Sec.
B.dP.C. for this reason
It
Plgn check The Cf)'
Date: PLUMBING PERMIT ISSUING FEE i
Slgpatur.
TOTAL FEE
Aran check applicant 5
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby off I"that I am exempt from the Contractor's Ucerse 118.50Law for the following reason (Section 7031.5, Business and
Address 3307
Professlors Code): -city Tel. No. 1 ITEM
❑ I, as owner of the property,will do the work and the 118-51113
/ -/1 �y
structure Is npt.intend1ed or offered for sale (Section pip. 8 ors' �
7041, Business and Profeaslons Code). LECH 118.50
CONSTRUCTION LENDING AGENCY
DID
I hereby affirm that there Is a cbnstruction lending agency for ■
the perfotmbnce.of the work for which this permit Is Issued
(Sec 3097, Cl V. C.
LendeWs Name 1 12/18/89
7M 1 Af110=5n.�
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 lays regulating Plumbing, and hereby
authorize reprelentatives of this County to enter upon the
qrbove-m tion property for Inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
$Igna ure of Permittee Date