HomeMy Public PortalAbout6100 IVAR AVE_Plumbing__ _4 "WORKERS,,COMPENSATION PECLARATION 0 0 0 0 0 o a
r I ,KeMebVyaffirm,thah I have a certificate of consent to self 76A667A appdOC�Q�00�1 FOR Q pdMG�iv f3�f 1C� p Q ��
`in$urg,r qr'a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) -
'or a gertified copy thereof (Sec.,3800, Lob.-C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished.
El Certified
APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS UO
tion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' {� BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL
ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ ny 4th
any m ner SINK CITY TEL. NO./ 1�?
so as to become subject to the W ers n ws. 4
DISHWASHER CONTRACTOR , �
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, aft r a ate of ADDRESS
Exemption, you should become subject to th orkers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL. NO
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
. LICENSED CONTRACTORS DECLARATION DISTRICT NO. P O SSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER 5-,
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM DATE L VALI ION C96®
`�j
License Number Lic. Class (%
FIN
Contractor Date BY
❑ I am exempt under Sec.
B.&P.C. for this reason
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name e
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031:5, Business and Address �— 2 2 7 5 4 A
� IPr fessions Code): Ci PL �"t"' Tel. No. bC �U
# 000005
" 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). J o 0 5 2 5 0
CONSTRUCTION LENDING AGENCY 0 0 0 5 2 5 0
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued 0 8.2 0-8 5
(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 la�.f
regulating Plumbing, and hereby
authorizeWe
ti
County to enter upon the
ab ve- eection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
S natureDate