HomeMy Public PortalAbout5831 OAK AVE_Plumbing__ WORKERS COMPENSATION DECLARATION ,i 't �P, "A8e7A f
I hereby affirm that I have a certificate of consent t4 self cE!17(z 8e1,*f,.P L I C A T I O N FOR PLUMBING PERMIT
insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C)
394512 Aetna Ins COUNTY OF LOS ANGELES BUILDING AND SAFETY
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 inspection NUMBER FIXTURE OR ITEM FEE ADDRESS 5831
oak Ayp-
J p��7�y WATER CLOSET ][ADDRESS
ALITY
Temple C-Ity
Datemn Applicant a•»1'1 Bmg.pl-b�.__ REST
BATH TUB SS ST
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE SHOWER ER Chris Construction
LAVATORY L
(This section need not be completed if the work involved 2 1 Flo n }
by the permit is for one hundred dollars ($100) or less) SINK _ aYAre-arli TEL NO O
1 certify that in the performance of the work for which this DISHWASHER U
permit is issued I shall not employ any person in any manner TRACTORso as to become subject to the Workers Compensation Laws CLOTHES WASHERDate Applicant SWIMMING POOL RECEPTOR RESS 26 N Baldwin Ave v
NOTICE TO APPLICANT If after making this Certificate of CITYUte TEL NO d
Exemption you should become subject to the Workers LAWN SPRINKLER SYSTEM STATE
Compensation provisions of the Labor Code you must forth T LICENSE NO 231 741 C gg�i36-20 CO)
with comply with such provisions or this permit shall be WATER HEATER [!
deemed revoked GAS SYSTEM OUTLETS DISTRICT NO PROCESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM A4
9 (commencing with Section 7000)of Division 3 of the Bust FINAL VALIDATION
ness and Professions Code and my license is in full force and DATE L Z
effect
License Number 231 741 Lic Class C36-20 BY AL
Contractor0wan BrOS._P_1b$lete 8/23/82
❑ I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051 Bus
iness and Professions Code) TOTAL FEE
Lic or Reg No Date Plan check applicant
HOME OWNER BUILDER DECLARATION Name .25953A
I hereby affirm that I am exempt from the Contractors Address # • • • e • 5
License Law for the following reason (Section 7031 5 Bust City Tel No 2r• • 5 2 5 0
ness and Professions Code)
ElI as owner of the property am exclusively contracting • • • 5 2 5 0 53with licensed contractors to construct the project
(Section 7044 Business and Professions Code)
0831 -82
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 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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
Tbve mentioned property for inspection purposes
Ve
8/23/82
of Permittee Date