HomeMy Public PortalAbout6052 KAUFFMAN AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I_have a certificate of consent to self 20.0026 DPW 6/87
insure, or a certificate of Workers' Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800, Lab, C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
❑ Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN-(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS 2- k t Ave ,
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applican4 WATER CLOSET NEAREST �+ I
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST. 'Dei
COMPENSATION INSURANCE SHOWER OWNER �" e—
(This section need not be completed If the work involved by MAIL
the permit is For one hundred dollars ($100)or less.) LAVATORY ADDRESS tA L4 f t , Q
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY T i� TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER ( /
CONTRACTOR ��J
Date Applicant CLOTHES WASHER ADDRESS ��``
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL. NO.14j+L
Compensation provisions of the labor Code, you must forth- LAWN SPRINKLER SYSTEM Y ad "�
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICO . ROCES E BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS Q'
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL /ATION �l
DATE � 0.
License Number Lic. Class 0.
FINAL ��. - �
Contractor _Date BY
❑ t, h-'
I am exempt under Sec. W
B.&P.C. for this reason �1� ��t b��� CL�
Plan check fee ► i �� z
Date: PLUMBING PERMIT ISSUING FEE$ 00
Signature
TOTAL FEE ao,5
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name N�
U_
I hereby affirm that I am exempt from the Contractor's License
)<CHANG
&Law for the following reason (Section 7031.5, Business and Address �Professions Code): City Tel. No. ,[U,_tE
I, as owner of the property, will do the work and the ITEMS
structure is not intended or offered for sale (Section
7044, Business and Professions Code). 20 ,n50
CONSTRUCTION LENDING AGENCY ?ij,1i1
I hereby affirm that there is a construction lending agency forthe performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name Er1 1_�IAll1 6 7 19f I
Lender's Address 1143 1 AN :02,
1 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
�bove-mentioned*property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE .
Signature of Permits D to