HomeMy Public PortalAbout6356 OAK AVE_Plumbing__ WORKERS''COMPENSATION DECLARATION 78A47A
1:•hereii9 affirm that I have a certificate of'consent to-self CS "70-80) APPLICATION FOR PLUMBING PERMIT
insure,or a certificate of Workers'Compensation.Insurance,or
a certified copy thereof(Sec 3800,Lab.C.) J
�utv� COUNTY OF LOS ANGELES � � BUILDING AND SAFETY
P.olicy No Company 'ET�4rE
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING r !e
' ADDRESS N• F�Gt.K
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE _
d pa�me Z. !4bg LOCALITY f
Date ��'' Applicant L► /s WATER CLOSET �e `e IL�
NEAREST
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' �
COMPENSATION INSURANCE SHOWER OWNER a
(This section need not be completed if the work involved LAVATORY MAIL Al >_ADDRESS 6 err /V. �6L� f/�C,. CL
bythe permit is for one hundred dollars ($100) or less.) O
SINK CITY•%l `I� TEL.NO. V
I certify that In the performance of the work for which this DISHWASHER ( r Cc
permit is issued, I shall'not employ any person In any manner. CONTR,ICTOR-� P�. O
so as to become subject to.the Workers'Compensation Laws. CLOTHES WASHER ADDRESS j
Date Applicant SWIMMING POOL RECEPTOR / a -
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO. co
Exemption, you should become subject. to the Workers' LAWN SPRINKLER SYSTEM STATE ' LIC.
Compensation provisions of the Labor Code,.you must forth- WATER HEATER
NO-312.4,00 CLASS ,3,.
W.th comply with such provisions or this permit shall be
deemed revoked.. GAS,SYSTEM 3 OUTLETS DISTRICT NO. PR CESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER !� x
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division.3 of the Busi= FINAL-. '
ness and Professions Code,,and my license is in full force and DATE 783 VALIDATION
effect.
° 22400. 36 FILie.Class. BY NAL
-31
License Number (�++ /f �C� '
Contracto;! uU WI .1t aO 11 s Date ,
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING. FEE$
acting in my professional capacity-(Section 705'1, Bus- 0a
iness and Professions Code). TOTAL FEE i6
Lie.or Reg.No. Date Plan check applicant'
HOME OWNER-BUILDER DECLARATION Name
I hereby 'affirm that I am exempt from the Contractor's Address
License Law for the followingreason (Section,7031.5, Bust- City Tel.No. 4 3'Q,3 A
ness and.Professions Code)::
Ell, as owner of the property, am exclusively contracting
# 0.'0.0 0 0 5
with licensed contractors to construct' the project + •
(Section•7044,Business and Professions Code) Z a c 4 4.5 0
CONSTRUCTION LENDING AGENCY 0 - 41L5030:
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is 0 608-82-
issued
08_82,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
a. -mentioned property for' spection purposes.
Signature o Permittee Date y