HomeMy Public PortalAbout5761 OAK AVE_Plumbing__ KERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
*� 20.0026 DPW 4/87
y affirm that I have7a certificate of consent to self in 76A667A tiUI
• sure or a certificate of Workers Compensation Insurance or a CE 817(REV 8/86)
certified cepy thereofec 3800 Lab C )
Policy No Company O COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Certified copy is hereby furnished I
ILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) / p
Certified y i with the county building inspection DDRESS
de " NUMBER FIXTURE OR ITEM @ FEE q ^�
Ail- sLX V IV LOCALITY 0.¢. 44 1 `4
Date Applicant WATER CLOSET(TOILET) '- NEAREST
CERTIFICATE F EXEMPTION FROM WORKERS Z
BATH TUB Z. „� CROSS ST I lb +$
CO PENSATION INSURANCEy SHOWER ' NER a(�
(This sedion need not be completed if the work involved by p
the permit is for one hundred dollars(:100)or less) LAVATORY +^ DDRESS a
1 certify that in the performance of the work for which this per SINK `
mit is issued I shall not employ any person in any manner so — CITY ay�.�g Rte/ TEL NO.,1�
as to become subject to the Workers Compensation Laws f DISHWASHER v
9NTRACTORgr ���
Date Applicant r CLOTHES WASHER ADDRESS MVR p o n
NOTICE TO APPLICANT If after making this Certificate of Ex SWIMMING POOL RECEPTOR
emption you should become subject to the Workers Compen CITY 12 ,TEL NO p -3-P>
sation provisions of the Labor Code you must forthwith comp LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok STATE LIC
ed WATER HEATER LICENSE NO C1A55
LICENSED CONTRACTORS DECLARATION r �+ ISTRICi R ED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS /v�
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
fed Professions Code an my license is in full force and of 5 PER SYSTEM FINAL VALIDATION O
DATE
License Number 6sL Lic Class V
FIN Q
Contractor ate BY O
t-
I am exempt under Sec --------------
V
W
B&P C for this reason Plan check fee
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Z
Date "•
i Signature PLUMBING PERMIT ISSUING FEE$
� TOTAL FEE
V V
SINGLE FAMILY
HOME OWNER BUILDER DECLAR TION Plan check applicant
r
I hereby affirm that 1 am exempt from the ntractor s License Name
Law for the following reason (Section 70 1 5 Business and
Professions Code) Address i :E
I as owner of the property will do the work and the City Tel No „X_r
100 CIl
structure is not intended or offered for sole(Section 7044
Business and Professions Code) ► t .e EG
CONSTRUCTION LENDING AGENCY II+Irl- 100,.50
I hereby affirm that there is a construction lending agency forCHECk 4 ('I td+
the performance of the work for which this permit is issued
(Sec 3097 Civ C ) + tj00
V +
Lender s Name •
Lender s Address i1 _ 47 � O
1 certify that I have read this application and state that the ► -+-j AM v jw
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
above mentioned property for inspection purposes +
V� 1 Ili SEE REVERSE FOR EXPLANATORY LANGUAGE
e
Signature of Permittee Da