HomeMy Public PortalAbout6048 CAMELLIA AVE_Plumbing__ �VORfCERS'COMRENSATION DECLARATION
20-0026 DPW APPLICA`�ION FOR PLUMBING PERMIT
I-hergby, affirm that I have a certificate of consent to self In- •7b�7A
sure,or p certlflcate of Workers'Co
mp�nsatlon Insurance,ora 8I7(may. 8/86)
certified copy thereof (Sec. 3800, Lab. C:)
Policy No.� Company COUNTY OF LOf -ANGELES :: T
113E .-OF PUBHC•WORKS\ ,
Cerltfled copy Is hereby furnished. BUILDING `
FOR APPLICANT TO FILL IN.(PRINT OR TYPE) p
Certified copy Is flledwlth thecoun uNd g•In ctl I,DDRE.LS O
department. NUMBER FIXTURE OR ITEM Q FEE'r. LOCALITY
Date Appllcan
WATER C105FI.(TOILET) �V NEAREST
QERtIFICATE QF EXEMPTION FROM WOR RS' BATH TUB C?Q55 ST.
COWENSATION-INSURANCE SHOWEROWNER
(This section rtia+d not be completed If that work 11"olwd by MAIL
the p"It Is for ono hundred dollars ($100)or 64.) LAVATORY ADDRESS . ]
I certify that In the pe4formdnce of.the work for which this per-
SINK
mit Is Issued, I shall not employ any porion In pay manner so Q �' �n Tom^ NO
w To be4ptne subject tb the Workers' Compensation Laws. DISHWASNEkQ CONTRACTOR
Dais- Applicant CLOTHES WASHER
IZ
NOTICE TO APPLICANT: If, after making this Cerilffcate of Ex- ADDRESS
- ^ SWMMING-POOL REt�FTOR
TEL erriptlon,you should become sublIect to the Wor-kers'Compen CITY TNO
satlon provisions of the Labor Cgde,you rputt forthwith comp- r LAIVN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed rbvok• STATE UC `oJ_
ed. + WATER HEATER UCENSE NO. CLASS
LICENSEDCONTRACTOR$DECLARATION DISTRICT NQ SSED BY
I hereby affirm that lam licensed udder provlslOns of Chapter GAS SYSTEM OUTLETS r,
-O
9(commencl-ng.wlth Section 7000)of Division 3 bf the Business
OUTLETS OVER �� 'r
feET,Professions Code end my license Is In full fbrce and eft 5 PER SYSTEM FINAL VALIDATIO a
DATE CL
License Number Llc.-Class V
_ FI �
Con'tractor Date, f O
QI•am exempt under Sec._ W
B.BP.0 'for this reason Plan check fee ,
Date: PLUMBING PERMIT ISSUING FEE$
$Ignature TOTAL FEE i
SINGLE FAMILY -•
+TOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby of lim'thaf l am exempt from the ContYnctor'r Llcertse Name
Law for the follpwing reason (Section 7031.5, Business andrt7.1
Professions Code): Address
I, os owner of the property, will do the,work and the Clty Tel. No.
structure Is not Inter4ed or offered forsale(Settlor+7044, i z
Ouslness and professlor)i Code). O _
CONSTRUCTION LENDING AGENCY , �!}(ilk130- r�
I hereby affirm that there Is'o constructlon lending ogency for }' l v 1313-513
the performance of the work for which this permit Is Issued GE '
(Sec.'3097, CIv. C.).
Lende'r's Name -IM4 XII 4/14/639
Lender's Address 1r�11
I certl# That I have read This application and state that the
above Informotlon Is correct. I agree to comply with all County ►
ordinances and St¢te laws regulating Plumbing, and hereby
author) p ntatly this County to enter upon the
aboV srl+o pr or Inspection purposes.
SEE REVERSE VOR EXPLANATORY LANGUAGE
4 '
Signature a ee Date