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Home My Public Portal About6037 CLOVERLY AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING. PERMIT 20-0026 DPW 4/90 1 hereby,'affirm that I have a certificate of consent to self in- 76A667A sure, or a certificate of Workers'Compensation Insurance,ora certified copy thereof (Sec. 3800, Lab. C.) 06(21t•'9l. 9 �JN fl 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 q )) Certified copy is filed with the unty b in inspection ADDRESS 0J,7 C(pJ�� department. NUMBER FIXTURE OR'ITEM @ FEE LOCALITY WATER CLOSET(TOILET). j/©. ��^^ �e i Date (.-IS-9G Applicant NEAREST. .� CERTIFICATE OF EXEMPTIOM WORKERS' BATH TUB CROSS 57. N Oc3 a v�W COMPENSATION INSURANCE SHOWER' OWNER aR t' V ie NGS � u5 (This section need not be completed if the work involved by MAIL / the permit is for one hundred dollars($100)or.less.) LAVATORY 59 ADDRESS `7d37 CIU�er 1 certify that in the performance of the work for which this per- SINK e CITY �• � TEL. NO. Z O�_ mit is issued, I shall not employ any person in any manner so �� t enn v i7 03 6Z as to become subject to the Workers'Compensation Laws. DISHWASHER i CONTRACTOR Weit COCA Co".1 1 rJc 1D/; Date. Applicant t CLOTHES WASHER ADDRESS 333 s. 9T� NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- CITY TEL. NO. sation provisions of the La L--.j,Code, you must forthwith comp- LAWN SPRINKLER SYSTEMS � ly with such provisions or this.permit shall be deemed revok--STATE . o LIC. 63 ed. WATER HEATER LICENSE NO. (0S'7S o0 CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed underrovisions of Chapter GAS SYSTEM 3 OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL, VALIDATION fect. (� 7- HOSE BIB DATE _ License Nu er �sg0 Lic. Class t✓ IL FINAL J 0 Contractor Date "�1-9 BY U ACCT.a �. 1 am e empt under Sec. c. 3303 183.30 V B.&P.C. for this reason1 ITEMS a Plan check fee . ► Date: PLUMBING PERMIT ISSUING FEE$ L/? TOTAL x..821 -30 � SignatureCHECK 188.3�1 TOTAL FEE SINGLE FAMILY CHANGE .00 HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name- Law for the following reason (Section 7031.5, Business and Professions Code):, Address 3®33 �� 9-i L 0000"0001 frl��gj I, as owner of the property, will do the work and the City re-C. Tel. No. i44$o`2ot4t� 7109 1 ��M 1 c 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 a horize representatives of this County to enter upon the a ve-m n' ed property for inspection purposes. t; SEE REVERSE FOR EXPLANATORY LANGUAGE �4S,-914 S g ature of Permittee Date