HomeMy Public PortalAbout6128 IVAR AVE_Plumbing__ i
?✓YORKERS COMPENSATION DECLARATION n ��p �� n S��O(�p 2OI� .�n p p.11ll��np� n��n/T��
S '}hereby, affirm that I'have a certificate of consent to sel ein- 76A66 A 0-0026 PW aiB7 LS li�l 11 I1V FOR L�lUJI1Vl1 o IIV Ifs I1VIl
sure,ocopy thereof (Sec. 3800, Lab. C.)
r a certificate:of Workers'Compensation insurance,ora ;CE
certified 817(REV:8%86)
"
- COUNTY OF,LOS ANGELES DEPT.-OF. PUBLIC WORKS
Policy No: Company
Certified co'py.is.hereby furnished
` Certified copy'is filed with the county building inspection
ADDRESS
❑ FOR.APPLICANT TO FILL IN (PRINT OR TYPE) i ,
departure t. FIXTURE.OR T @ FEE LOCALITY �/
c '. WATER CLOSET(TOILET)EM
NUMBER �/)
.,Dote Applicant lCtl CROSSNEAREST.
CERTIFICATE'OF EXEMPTION• ROM WORKERS'.' BAT B a®
COMPENSATION INSURANCE OWNER ' C `
(This section need not be,completed if the work-Involved by SHOWER 'MAIL � ��
the permit is for one hundred dollars ($1100)or less.) LAVATORY ADDRESS /{ o v
(:certify that in the performance of the work for which this per-
..
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mit is issued,•(shall'not employ an person in an manner.so 'SINK TEL'. NO^.�
P. Y Y P Y• CITY N d �"OJ
as too a subject to the Workers Compensa��ws.-
'bec ,
DISHWASHER /�
CONTRACTOR ,?
`�,
Date Applicant ��� CLOTHES WASHER`
NOTICE T APPLICANT: If; afteHm ng rthis Certificate of'Ex- ADDRESS
em tion; ou should become-sub'ectto,the.Workers'.,Com ,eri SWIMMING POOL RECEPTOR__ r
P Y I P � �.. ^.'CITY .' _ TEL. NO..
sation provisions of.the Labor,Code,'you must forthwith comp- LAWN SPRINKLER SYSTEM,
jy with such,provisions or this permit shall be deemed_revok- STATE LIC.
-ed. ': WATER HEATER
LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION, `
I hereby
affirm
wahI,am li n7000 of Devision'31'of he Bustin" GAS SYSTEM OUTLETS
DISTRICT NO. ROCESSED BY '
Y p pierr�
' ( g ) Business - OUTLETS OVER
and Professions Code, and my,license is in full force and ef- FINAI
fect. .., .. . �lj — p
5 PER SYSTEM
DATE Z VALIDATION
License Number,- tic. Class" ''
U
FIN
Contractor " Date
6
BY � 0.
EY I am,,'exemptunder Sec.-----:--
LU
IL
B 8P C for this reason
Flan cheek fee �-
g.
Date:
PLUMBING PERMIT'ISSUING FEE$
Signature _
SINGLE FAMILY
TOTAL FEE Q
HOME'OWNER-BUILDERIDECLARATION' Plan:check applicant
I hereby offirm,that I am exempt,from the Contractor's License,' -Name
Law for the following'reason (Section -7031.5, Business.and '
Professions Code):.
4..
Address
Azii
1, as owner of the.property; :will'do-the work,and the City t Tel. No. i
structure is not intended or bffered for sale(Secnon 7044; :.
Business and Professions Code) ' '' r =. ' , y t =
CONSTRUCTION LENDING AGENCY =D . ti rI `I
''.
I hereby affirm that there is'•,a construction lending agene`.for I ES,
the performance.of the work.for which this permit,is,issued
(Sec. 3097'"Civ. C.);
Lender's Name '•_•i#L{. ftu�_;E s
Lerider's Address s ` ' �1 IJ I
I certify that l have read this application and state that the
above information is correct 'I agree to comply with all County
ordinances-and.State Iotas regulating Plumbirig,.and hereby D }_11_'_11 .il) i 'T" i
authorize representatives of this County to enter-upon•the _ t _
above-mentioned propert for inspection,pure ses. ta ._, i tib __ t
3� ./. SEE REVERSE FOR.EXPLANATORY LANGUAGE
Si ture.of Permittee Date