HomeMy Public PortalAbout5827 OAK AVE_Plumbing__ WP*RKERS COMPENSATION DECLARATION DPW 4/90APPLICATION FOR PLUMBING PERMIT
I hereby afftrrrPthat I*have a certificate of consent to self in 76A667A
sure or a ebrtrficate of Workers Compensation Insurance or a
tertified copy thereof(Sec 3800 Lab C)
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy No Company
❑F1 Certified copy is hereby furnished FAMDDRESS
FOR APPLICANT TO FILL IN(PRINT OR TYPE) p r"l �� �D
Certified copy is filed with the county budding inspection 7 a ` 4
department NUMBER FIXTURE OR ITEM ® FEE TQ
us
NE
WATER CLOSET(TOILET) /Q !C./n
Date Applicant NEAREST f
EST
S TU
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB COMPENSATION INSURANCE SHOWER(This section need not be completed if the wolk inbolved by ,/the permit is for one hundred dollars($100)or less) LAVATORY 2 10 /r f!e
I certify that in the performance of the work for which this per SINK TEI NOmit is issued I shall not employ any person in any manner so bio
as to become subject to the Workers Compensation Laws ! DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making this Certificate of Ex SWIMMING POOL RECEPTOR
emption you should become subject to the Workers Compen CITY TEL NO
satron provisions of the labor Code you must forthwith comp LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok STATE MIC
ed ' WATER HEATER LICENSE NO i
LICENSED CONTRACTORS DECLARATION DISTg(7 NCS BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS d� ('A
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER •60
and Professions Code and my license is in full force and of 5 PER SYSTEM FINALQ �w
fect HOSE BIB DATE �L— "i V w !�
License Number Lic CIO ss
TOTS 2M
FINAL OECK M6.60 V
Contractor Date BY 1C
1 am exempt under Sec '00 0
V
B&P C for this reason Plan check fee W
DatePLUMBING PERMIT ISSUING FEE$ a Q 1 10� 2/9 Z
Signature 1 PM 5:27
TOTAL FEE 3 6 a
SINGLE FAMILY l
HOME OWNER BUILDER DECLARATION Plan check applicant ,
I hereby affirm that I am exempt from the Contractor s License Name
Law for the following reason (Section 7031 5 Business and
Professi Code) Address
I as o
wrier of the property will do the work and the City Tel No
structure is not intended or offered for sale(Section 7044
Business and Professions Code)
CONSTRUCTION LENDING AGENCY
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 Cft
)
Lender s Name P
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
outhonziNepresentatives othis County to enter upon the
1(xkire ion o ►tY f inspection purposes
2•Q S SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa a er t Date