HomeMy Public PortalAbout6046 CAMELLIA AVE_Plumbing__ * RqRs'roMPE"spTl°" DECLARATION APPLICATION FOR PLUMBING PERMIT
716ergby,vfFlrm that I have a certificate of consent to self In- DPW 41E7
764667A
sure,or a cealflcate of Worker'Compensation Insurance,ora 817(may BiBb)
C
cdpy thereof (Sec. 3800, Lab. C,).
' COUNTY OF LOS ANGELES } DEPT. OF PUBLIC-WORKS
Poll Icy No. Cpmpany
0 Certified copy Is hereby furnished.
FOR APRKANT TO FILL IN(PRINT OR TYPE) BUILDING
Certl#led copy Is filed with the tour building In tl gDDTtE55 {0
department. NUMBER FIXTURE OR ITEM B FEE LOCALIII
Date 3 WATER CLOSET(TOILET)
Applicant
CERAFICATE OF EXFJJII�TION FROM W RKER RATH TUB OQ CROSS�'
COMPENSATION INSURANCESHOWERO 01NNER
(This section need not be completed If the work Involved by
the pef-tt lir for one hundfed dollars($100) or less.) LAVATORY
I certify that In the performance of the work for which this per-
mit Is Issued, I shall not employ any person In any manner so4NK 01Y v!l M TEL.
as to become sublets to the Workers'Compen$rtlon Laws.
DISHWASHER CONTRACTOR
bate Appllcant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption,you shduld become sub ect to tha-Workers'Compen- r
CITY TE4 NO.
satlon,provl+lons of the labor Code, yoif must forthwith comp- .� L,gy1gJ SPRINIQEIZSYSTEM
ly with such provlslons or this permit shall be deemed revok- STATE LIC_
ed. WATER HEATER UCBJSE NO. C1ASS
LICENSED CONTRAC70RS DECLARATION DISTRICT NO. BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of DIvIsIcn 3 of the Business OUTLETS OVER S, (�
and Professions Ccdb, and my license Is In full force and of- 5 PER SYSTEM FINAL VALIDATION
fact. DATE �� CL
O
License Number Llc.•Class r U
Fl rs
Contractor Date O
I am exempt under Sec. W
l
B.BP.C. for this reason
Plan check fee Poo.Dm° PLUMBING PERMIT ISSUING FSE$
Signature TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant
.r
I hereby affirm that I am exempt from the Contractor's License Name y
Law for the following reason (Section 7031.5, Business and ACC.7
Professlons Code): Address
-7307 124.`3
I, as owner of the property, will do the work and the City Tel. No. 1 1TEn
-ritructure Is not Intended or offered forsale(Section 7041,
Business and Professions Code). oil G
CONSTRUCTION LENDING A -,NCY F r l
I hereby offlrm thgt there Is a construction lending agency for
the performante of the work for which this permit Is Issued00
(Sec. 3097, Civ. C.).
Lender's Name
Lenders Address 1 AN 8;01
I certify that I have recd this application and state that the oil.
Information Irl correct. I agree to comply with all County
ordinances and State law& regulating Plumbing, and hereby
authoriz esentatives of Is Co ty to enter upon the
obc, tlon pro Insp tion purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
`I Igna ure of P I Date