HomeMy Public PortalAbout6251 IVAR AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION A(;�[p'�p CATION 'FOR PLUMBING
fin p i{ BING PERMIT
Lhereb affirm that I have a certificate of consent to self in- 20-0026 DPW 4/90 I! If L� ll I1�1 lf'L�l�I9�F1 i
y� 76A667A
sure;or a certificate of Workers'Compensation Insurance,or a
certified copy thereof(Sec. 3800, Lab. C.) '
:�y�3G3 G COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No/ Company �k'G
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS
NUMBER FIXTURE OR ITEM FEE LOCALITYj�f��
department. - @ ,r
Date 12' 7-16- Applicant . : WATER CLOSET.(TOILET). NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB ,.1' CROSS ST.-
COMPENSATION
T.COMPENSATION INSURANCE SHOWER OWNER
' .
(This section need not be completed if the work involved by MAIL f,Q
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK �y
mit is issued, I shall not employ any person in any manner so CITY TEL. NO12-02_-
as to become subject to the Workers'Compensation_Laws. '• p DISHWASHER
0 CONTRACTOR6'Jj'�jGJ'S�
Date Applicant " CLOTHES WASHER ,ADDRESS / ' /, F.G6sjJ ✓�'r-�
NOTICE TO APPLICANT: If, after making this,Certifii ate of Ex- 1&g;A S�
emption,you should become subject to the Workers Compen- SWIMMING POOL RECEPTOR f
CITY TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit-shall be deemed revok- STATE LIC.
ed.. WATER HEATER LICENSE NO. �� CLASS
LICENSED CONTRACTORS DECLARATION .• DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with'Section 7000)of Division 3 of the Business / OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
fect. HOSE.BIB DATE
License Number ' '��� Lic. Class O
FINAL V
Contractor/*f � �� ate .�ZBY
5 fS
El I am exempt under Sec. ®r �
A�:cTa
B.&P.C. for this reason ,�.3
Plan check fee 33 3 �'
3 3_� 50 �
Date:` PLUMBING PERMIT ISSUING FEE'$
SignatureIT
SINGLE FAMILY TOTAL FEE '-3. TOTA� 53 .50
HOME OWNER-BUILDER DECLARATION . Plan check applicant.
I.hereby affirm that I am exempt from the Contractor's License Name CHECK 353.50
Law for the following reason (Section 7031.5, Business and
�A �E e�4
Professions Code): Address
ED1, as owner of the property, will-do the work and the City Tel. No.
structure is"not intended or offered for sale(Section 7044; 0000-0001 12/ 7/95
Business and Professions Code).
CONSTRUCTION LENDING AGENCY 3641 I AM 10:ib
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
authorize representatives of this County to enter upon the
ob - ntione roperty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
r Signature of Permittee Date