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Home My Public Portal About5755 CLOVERLY AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT Irherel�y affirm'that I have a certificate of consent to self 76A667A insure, or a certificate of'Workers' Compensation Insurance, CE 817(REV. 10/81) �J or a certified pthereof'(Sec3800 La C. COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. /J95CompanyL ❑ Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ertified copy is filed with the county building inspec- ADDRESS Jle r e\,, r tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY 2T WATER CLOSET Date o � Applican NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' I BATH TUB Zed CROSS ST. COMPENSATION INSURANCE OWNER �/e.dQ f� SHOWER C ///• A11 (This section need not be completed if the work involved by MAIL $ the permit is for one hundred dollars ($100)or less.) LAVATORY b Q ADDRESS I certify that in the performance of the work for which this SINK CITY TEL. NOcl ) 37? permit is issued, 1 shall not employ any person in any manner Gt+^ so as to become subject to the Workers'Compensation Laws. DISHWASHER 6 CONTRACTOR Date Applicant CLOTHES WASHER ADDRESSlI NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR /y�,�; JJ� A Exemption, you should become subject to the Workers' CITY/ �cev` TEL. NO.II 3— Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM _ with comply with such provisions or this permit shall be STATE ® (� / LIC. deemed revoked. WATER HEATER D LICENSE NO. J �( -s�+' CLASS LICENSED CONTRACTORS DECLARATION DISTRICT O SSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 1.(/sz1(©/ (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER - and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDA ON License Number �7J �/ Lic. Class DATE Q t+ /��_ FINAL U. Contractor &_�f & Date " / BY ❑ I am exempt under Sec. X 6 5 6,7 A o B.BP.C. for this reasonPlan check fee ► # 0•0 0 0 0 5 CL ' Dat PLUMBING PERMIT ISSUING FEE$ I o o 4 6,5 0 Z Signature, _—/-/-✓6�•.¢�i//�b /� TOTAL FEE W�7 0 0 046,5.0 Plan check applicant SINGLE FAMILY 0 2 2 4-8 7 HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name 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 representatives of this County to enter upon the above-mentioned property f �iine,,cfion purposes._ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Perm ttee Date