HomeMy Public PortalAbout6142 IVAR AVE_Plumbing__ ►' RKERS'COMPENSATION DECLARATION p p p �p
ereb,'affirm that I have a certificate of consent to self 20-0026 DPW 6/87 ���L���Q��O�V �O� ���� °o �� '" ��--���
J 'Y
•�'vasure,.or a certificate of Workers' Compensation Insurance, 76A667A I f,
?or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS �f
_i cy NoWC400 28 0; „pang CNA
EJCertified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
i3 �_ Certified copy is filed with the county building inspec- ADDRESS 6142 IVAR AVE. — TFIKPLE CITY
tea* tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date 2-1-99 Applicant OWEN PTIINRTNG _2 WATER CLOSET 12 CIEK
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' 2 BATH TUB '!2 OO CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER RAPID BUILDERS
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) 4 LAVATORY 24 0e ADDRESS 457 W. ALIAN AVE4108(?111)
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 CITY SAN DIVAS,CA-91773 TEL. NO599-0825
so as to become subject to the Workers'Compensation Laws, DISHWASHER
CONTRACTOR OWEN PLUMBING CO.
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR gDDRESS 20 SANTA A A
Exemption, you should become subject to the Workers' CITY L. NO. $[F
Compensation'provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM MONTQ 3-33
with comply with such provisions,or this permit shall be STATE LTC.
deemed revoked. WATER HEATERLICENSE NO. 4 CLASS (;-36
.
LICENSED CONTRACTORS DECLARATION 6 DD DISTRICT NO. ROCESSED/�Y
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 6 OO ` �
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL✓� b ATIO� p�,�
License Number DAT U.
451C3��Lic. Class C-36
FINA
Contractor OWEN PLUMBINGDate 2-1-89 BY Z A ®)
❑ I am exempt under Sec.
B.BP.C. for this reason CL
Plan check fee .
Date: PLUMBING PERMIT ISSUING FEE$ 10 go
Signature TOTAL`FEE 76 1.50 '
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name -
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5; Business and
Professions Code): City Tel.No.
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section D C
7044,'Business and Professions Code).
CONSTRUCTION LENDING AGENCY
;' 'I "
I hereby affirm that there is a construction lending agency for 1,t
the performance of the work for which this permit is issued —"
(Sec. 3097, Civ.C.). `.f t-s!'
Lender's Name 9 i_i j` = 50
Lender's Address t.:HEIC i; 1 =50
I certify that I have read this application and state that the rq! tsy;_I; ( I
above information is correct. I agree to comply with all County C'E" r— `'
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above ent'oned proper or inspection purposes. E_i_i_i sY -2! x
/2"=
i SEE REVERSE FOR EXPLANATORY LANGUAGE �'�= = -'
Sig ture of Permittee Date