HomeMy Public PortalAbout6221 HART AVE_Plumbing__ ,M;5k'kERS'C(3MI1ENSATION DECLARATION APPU t�`bAb MN FORPLU MMI PERMT,
er
•'I hereby,affirm that I have a certificate of-consent to self 76A667A
iDsure,'or,a certificate of Workers' Compensation Insurance, CE 817 (REST.8/86) �(
or a certifies copy 4_-reof (Sec. 3800, Lab. C.)
' ) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy i3 hereby furnished. BUILDING
/ �J y I�/�,/J
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS (D zz SAP 1
EJCertified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
CA
Date
WATER CLOSET, '01, �0 NEAREST
Applicant
CERTIFICATE•OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER
/ / s
SHOWER `Z 'U P rr'_I
(This section.need not be completed Wthe work involved by MAIL
the permit is.for one hundred dollars $100)or less.) Z LAVATORY " �, ADDRESS -5 Am G
I.certify that in the performance o work for which this
permit is issued, (shall not employ e o n any manner SINK CITY TEL NO. l I
so as to Tome subject to the Wo p sation Laws.
DISHWASHER CONTRACTOR' S
Dote 'Applicant , CLOTHES WASHER ADDRESS
NOTIC AP.LICANT: If, after making this Certificate of SWIMMING POOLRECEP,TOR
Exemption; you should becom subject to the. Work CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROLES BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,`and my license is in full force and effect. 5 PER SYSTEM FINAL V IDATION
._ DATE �' V
License Number, Lic. Class
FINAL
Contractor Date BY
❑ I am exempt under Sec.
B.BP.C. for this reason
'Plan check fee
Date; 7 8-9.6 A
PLUMBING PERMIT ISSUING FEE$ S� '
Signature
TOTAL FEE
!.� 0 0645 0
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name a o!6 6 4 5.05
I hereby affirm that I am exempt from'the Contractor's license
Law for.the following reason (Section 7031.5, Business and Address 0 9„1 'i'8 7
Professions Code): CityTel. No..
I, as owner of the property„will do the work and the
structure is not intended or offered for sale (Section D
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending.ogency 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 D
a v information is correct. I agree to comply with all County
d' an es and State laws regulating Plumbing, and hereby
Ifte
ntatives of this Count to enter upon the
propertyfor inspecti pur oses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
�;c 87
Signature of Permittee ir V F. Date