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Home My Public Portal About6044 CAMELLIA AVE_Plumbing__ WORKUS',COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby,efftrrn`t�id1 I have a cp4lflc t Sf cpnjent to self In- �DPW 487 APPLICATION sure,or a certificate of Workers'Comp hsatlorf Iruurance,or a CE 817(REV. 6/86) certified copy thereof (Sec-3800, Lab. C.) u COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy.No. Company Certified copy Is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy Is filed with the county building Inspection ADDRESS 1Q0 VA pw� department. NUMBER FIXTURE OR ITEM FEE LOCALITY y C—t Date Applicant WATER CLOSET(TOILET) NEAkEST CERTIFICATE OF EJDMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER � IT, is sectlon need not be cdmpleted H the work I"ohred by' V� 11 �1)� MAIL tori pertnM Is for one hundred dollar (;T00) or leu. LAVATpRY ADDRESS I certify that In the performance of the work for which this per- mit It Issued, I shall not employ any person In any manner so CNK CTTY_�� Lt "-�` TEL NO. 0&to become subject to the Workers'Compensation Law}. DL91(WASHER CONTRACTOR Data Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Ex SWIMMING POOL RECEPTOR emotion,you should become subject to the Workers'.Compen- CITY NO zbllon provisloni of the Labor Code,you'must forthwith comp- LAWN SPRINp82 SYSTEM Iy with such provisions or this permit shall be de*med revok- STATE LIC ed: WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION ef I hereby affirm that I am licensed under provisions of Chapter �SYSTEMOUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER fend Profesilorts Code,and my license Is In full force and ef- 5 PER SYSTEM FINAL ON d 1 FT DATE ALID O Llcense Number Llc. Class U FINAL Contractor Date BY O U I am exempt under Sec. 0 a B.BP.C. for this reason Plan check fee Poo. fie' PLUMBING PERMIT ISSUING FEE$ O Slgnatute TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant J I hereby affirm that I am exempt from the Contractor's License Name A Low for the following reason (Section 7031_.5, Business and ACCT•T Prof Ions Code): Address �7 20.50 I as owner of the property, will do,the work and the �Ity Tel. No. 1 ITEMS structure is not intended or offered for isle(Segtlon 7044, Buslness and Professions Code). � TOTAL 20 - 50 CONSTRUCTION I N LENDING AGENCY CHECK 20-9.0 I hereby affirm that there Is a construction lending agency for .(0 the perfortrwnce of the work for which this permit. Is Issued � tF (Sec. 3097, Clv. C_). Lender's Name 1 1/22/90 90 Lenders Address 1 AN 8'56 I certify that I have read this application and state that the above Informatlon Is correct. I agree to comply with all County , &dlnances and Stole lows regulating Plumbing, and hereby ; authorize representatives of this County to enter upon the abo mentlo pr for Inspection purposes. _ � _ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date 17; . "RS'COME-ENSATION DECLARATION \1 Lhergby,'affirm that I have certificate of consent to self in- SAD 4ie7 FOR PLUMBING PERM sure,or gcertificate of Workers'Compensation Insurance,or a CE 817(� g/86) ��APPLICATION certified'cepy thereof(Sec. 3800, Lab. C,) u policy No., [ Company UNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Certified copy Is hereby furnished. . FOR APPU___ FILL IN(PRINT OR TYPE) BUILDING \ I—I Certified copy Is filed with the county ulld nq In cti n NUMBER FIRE OR 4041 OVA-11I iA 4J department. e FEE / LOG41fFY Date ' Appllcont WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EX MPTION FROWORK RS' BATH TUB CROSS ST' M COMPENSATION INSURANCE SHOWER OWNER (This sectloe n need noT be completed If the work InvolvedbyMAIL C the permit Is for one hundred dollars (:100)or less.) LAVATORY r t I certify that 1n the performance of the work for which this per- /^� , mit Is.lssued, I shall not employ any person In any manner so SINK QL./ CLTY Vkill TEL NO. os to become subject to the Workers'Compensatlon Lows. . DISHwASFIHt CONTRACTOR G� �.(,l�I�l/!.C Data "Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certlflcn}e of Ex, ADDRESS emptlon,you should becomes act to the Workers'Compen- SWIMM1It FG POOL RECEPTOR CITY TEL NO. action provisions of the Labor C e,you must forthwith comp- ' LAWN SPRINKLER SYSTEM / ly with such provisions or this permit shall be deemed revok- STATE uC _ ed. WATER HEATER LHZENSSE NO. 177? CLASS LICENSED CONTRACTORS DECLARATION 42q DISTRICT NO. SSfD BY I hereby affirm that I am licensed under provisions of Chapter Gu SYSTEM � ! 9(commencing with Section 7000)ofDlvldon 3 of the Business OUTLETS OVER and Professions Code, and my license Is In full force and ef- 5 PER SYSTEM FINAL 0�'A7 VALIDfact. DATE License Number Llc_ Class U FIN Q Contractor Date 4 1– ❑ I am exempt under Sec. W a B.BP.C. for this reason . . Plan check fee ► � Data' PLUMBING PERMIT ISSUING FEE; Signature TOTAL FEE SINGLE FAMILY CP HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name Low for the following reason (Section 7031.5, Business and �\ Professions Code): Address, —2117 130.50 I, as owner of the property, will do the work and the City Tel. No. \; structure Is not Intended or offered for sale(Section 7044, Business and Professions Code). TOT.k 130 - '----10 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit It Issued {Sec. 3097, Civ. C.). - 1 _ Lender's Name Lender's Address ` te t 1 $:Irz 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 ntatives the County to enter upon the abov n for ction purposes. 1 SEE REVERSE FOR EXPLANATORY LANGUAGE 511 nature of Date