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Home My Public Portal About6350 OAK AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION 76ao67 1 z -eo) APPLICATION P®R PLUMBING PERMIT I h�teby A'd'am that I have a' certificate of consent to self ce srr insure,or a certificate of Workers'Compensation Insurance,or ry— a certified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy Nol. Company �%F� AZZAID Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ADDRESS 3S AJ ®Q K uc CQ Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM ® FEE depttme��t /� LOCALITY Daterypplicant� Qrl -Wlk �G, WATER CLOSET NEAREST I BATH TUB 4f CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER qOWNER �_AS4 jQ ,(pg LAVATORY MAIL >_(This section need not be completed if the work involved rADDRESS 6 3 J' Al. & a by the permit is for one hundred dollars ($100) or less.) SINK � CITY%� �� TEL.NO. � U I certify that in the performance of the work for which this DISHWASHER �1 0 permit is issued, I shall not employ any person in any manner CONTRACTORI lJ so as to become subject to the Workers'Compensation Laws. CLOTHES WASHER ADDRESS / W Date Applicant. SWIMMING POOL RECEPTOR n NOTICE TO APPLICANT: If, after making this Certificate of CITY 0 TEL.NO. ®J' y Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. Z Compensation provisions of the Labor Code, you must forth- LICENSE NO. d CLASS with comply with such provisions or this permit shall be WATER HEATER deemed revoked. DISTRICT NO PR CESS�EDB Y GAS SYSTEM 3 OUTLETS y— LICENSED CONTRACTORS DECLARATION OUTLETS OVER J '0 I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000)of Division 3 of the Busi- FINAL �P®�® VALIDATION ness and Professions Code, and my license is in full force and DAT effect. License Number 1 Q Lic.Class BY-'��p BY AL Contractor% SO/6 Date I am exempt from the licensing requirements as I am a Plan Check fee IPJ licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ 0 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 I hereby affirm that I am exempt from the Contractor's Address �,4 3 0.4 A License Law for the following reason (Section 7031.5, Busi- City Tel.No. 4 0 0 0 0 0 9 ness and Professions Code): 1, I, as owner of the. property, am exclusively contracting 2 ° ° 4 U.5 0 with licensed contractors to construct the project (Section 7044,Business and Professions Code). o 0 0 (i 4 5.0 CE CONSTRUCTION LENDING AGENCY 06.08-82 I hereby affirm that there is a construction lending agency for the performance o the work for which this permit is issued(Sec.3097,Civ/� J. Lender's Name pr r' 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 ZM�entioned property r inspectionpature of Permittee Date