HomeMy Public PortalAbout6374 OAK AVE_Plumbing__ 1,.PRKERj'COMPENSATION DECLARATION +rsaeszn
I hereby affirm that I, have a' certificate of consent to self Cr.e17 (z-eo.) APPLICATION FOR .PLUMBING PERMIT
i"ure,or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.. ,) ��
COUNTY OF LOS.ANGELES BUILDING AND SAFETY
-Policy No'�7. 000-Company
Certified copy Is hereby furnished. FOR APPLICANT TO FILLIN (PRINT OR TYPE) BUILDING
ADDRESS
Certified copy is filed with the county building inspection
NUMBER FIXTURE.OR ITEM , 0 FEE
LOCALITY -
WATER CLOSET
A 101-
Dat Applican NEAREST
BATH TU13 CROSS ST.. ool
CERTIFICATE OF EXEMPTION FROM WORKER
COMPENSATION INSURANCE SHOWER OWNER
MAI 14 r.
(This section need not be completed 'if the work involved LAVATORY ' AD D R EssOL. }
by the permit is for,one. hundred dollars ($100) or less.)%
t� 'SINK CITY TEL..NO. o
I certify that in the,performance of the work for which this DISHWASHERU •:
CONTRACTOR
'permit is issued, I shall not,employ any person in any.manner - �
so as to become subject to the Workers'Compensation Laws. CLOTHES WASHER ADDRESS
26 e4 Z Ae
Date Applicant SWIMMING POOL RECEPTOR �j
NOTICE TO APPLICANT: If, after making this Certificate of CITY, TEL.IVO. ' Q
Exemption, you should become subject to the Workers'" LAWN,SPR INKLER SYSTEM STATE � , LIC. /' N
Compensation provisions of the Labor Code,,you must forth- LICENSE NO.. 'ZdO CLASS (Q. 2
with comply with such provisions or this permit. shall be WATER HEATER m
deemed revoked. ;I DISTRICT NO.. PR CESSED B '
GAS SYSTEM OUTLETS
LICENSED CONTRACTORS DECLARATIONOUTLETS:OVER u
I hereby affirm,that I am licensed under provisions of Chapter 5 PER SYSTEM
9 commencing with Section 7000 of Division 3 of the Busi- FINAL
( ) DATE VALIDATION
nese and Professions Code, and.iny license is in full.force and
effect.
- - FINAL
A�
License Number Lic.Class ..�./ 3 BY
Contractor to— aSoU 3 0
I am exempt from the licensing'requirements as'I am a Plan check fee
licensed architect or a registered profe§sional engineer ,', PLUMBING PERMIT ISSUING FEE-$ -
acting in my 'professional capacity (Section 7051, 13us- ;
indss'and Professions Code,). TOTAL.FEE '
Lib.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 following.reason (Section.7031..5, Busi- City Tel:No.
ness and Professions Code.): �• ",
❑ I, as owner of the property; am exclusively contracting JR-'1 4 5.4 A
with licensed contractors to construct the project
(Section 7044,Business and Professions Code.). #,a. o•0 0 0 5.
CONSTRUCTION LENDING AGENCY Z ° q-37.00
I hereby affirm that'there is a construction lending agency :
for the. performance of the work for which this permit is •o o 0 3 7.0,0 6
issued(Sec.3097,Civ.C.). -6-81
Lender's Name
Lender's Address
I certify that I have read this application and state that the �
above information is correct.T 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
above-mention perty for inspection purposes.
Signat re bf:Permit ae Date