HomeMy Public PortalAbout6006 CLOVERLY AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
hereby lb{tirm that I have a certificate of consent to self 76A667A I '
r1sure,,or a cer61icate,bff.(mpany
orkers' Compensation Insurance, CE 817(REV. 10/81) u
1 or&--ere.ti d co y theSec. 3800, Lab, C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
y
Policy No.� d °Q
❑ 'Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS ����
tion department. j� NUMBER FIXTURE OR ITEM FEE LOCALITY. /�M t
Pp�G�i►'!b ",� Z. WATER CLOSET
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORK n M
.)_. BATH TUB Q CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) '7— LAVATORY O ADDRESS �) ✓d"/J/✓ �0�
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner / SINK A 140
CITY h/G ,CZ TEL. NO�f� ��S-/
so as to become subject to the Workers'Compensation Laws. DISHWASHER 00
CONTRACTOR 4 VI"J.,o G/
og
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Qum
Exemption, you should become subject to the Workers' CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION Q DISTRICT NQ CESSED BY
AS SYSTEM OUTLETS
I hereby affirm that I am licensed under provisions of Chapter 9 G
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL i VALID ION
DATE
License Number Lic. Class 3� O"� a
1 O
"P L1"� FINAL U.
Contractor Date
BY / I=
❑ I am exempt under Sec. /1 U
B.BP.C. for this reason Plan check fee
Date:
Signature PLUMBING PERMIT ISSUING FEE$ �4 4 S 9 A Z_
TOTAL FEE # 0 0 0 0 5 5
Plan check applicant
SINGLE FAMILY I 0 0 7 6 5
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address ° ° ° 7 5 Q CES
for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. OIL 1 7-86
❑ 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). poll
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 re sentatives of this County to enter upon the
above-mento ed property for inspection urposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature of Permittee Date