HomeMy Public PortalAbout6384 OAK AVE_Plumbing__ .WORX-ESS.COMPF4SATION DECLARATION 76A867A
I hereby affirm that 1 have a' certificate of consent to self ce s» (x-eo) APPLICATION F®R PLUMBING PERMIT
insure,or a certificate of Workers'Compensation Insurance,or �1
a certified copy
�7thereof(Sec.3800,Lab.C.) 1�� `fl
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.377630Companystate Fund
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) JROSS
UILDING 6
M Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM ® FEEaDate� 'r nt ODDRESS 34 N0 Oak Avenue
1ApplicanTruman SOl1S Plbgo 2 WATER CLOSET EAREST
CALITYTem le Cit California
1 BATH TUB ST. Olema Street
CERTIFICATE OF EXEMPTION FROM WORKERS' Hasa Robles Mission Ho
COMPENSATION INSURANCE ISHOWER OWNE
LAVATORY MAIL
(This section need not be completed if the work involved ADDRESS 63 55 No Oak Avenue
by the permit is for one hundred dollars ($100) or less.) 95
1 SINK CITYTemple City9 Cao EL.N2.286_ tl
I 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 CONTRACTORTruman Solis Plb o TncO
so as to become subject to the Workers'Compensation Laws. CLOTHES WASHER
ADDRESS 2661 Glen Avenue °
Date Applicant H
SWIMMING POOL RECEPTOR Altadena Califo 794-705
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO. W
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC.
Compensation provisions of the Labor Code,you must forth- WATER HEATER LICENSE NO. 12 OO CLASS C= 6
with comply with such provisions or this permit shall be 1
deemed revoked. ], GAS SYSTEM 3 OUTLETS DISTRICT NO. PR ESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER (3 /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
ness and Professions Code, and my license is in full force and DATE 7— " VALIDATION
effect.
License Number312400 Lic.Class C-36 FINAL
- -(LBY
• ;�
ContraetoTruman 301iSDate12-21=$1 3t,
F1 I am exempt from the licensing requirements as I am a Plan check fee • �,/
licensed architect or a registered professional engineer j,y J
PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). 50
TOTAL FEE
Lic.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name F 2 4 0 1 A.
I hereby affirm that I am exempt from the Contractor's Address # 0 0 0 0 0 5
License Law for the following reason (Section 7031.5, Busi- City Tel.No.
ness and Professions Code): 2 - 41l,50
I, as owner of the property, am exclusively contracting o 0 0 � 4. F r=
with licensed contractors. to construct the project
(Section 7044,Business and Professions Code).
12.21 -E1
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.). None
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
o e mentioned proper=f ' tion purposes.
Signature of Permittee Date '