HomeMy Public PortalAbout6412 OAK AVE_Plumbing__ i yivORKER3'rCOMPENSAT16N DECLARATION APPLICATION FOR PLUMBING PERMIT l�
' 1!+%1.here�15ffirm that I ff6ve a certificate of consent to self 7SA667A I I
in rer a certificate of Workers'Compensation Insurance, CE 817(REV.8/86) LI
�' or ctrtifieif copy thereof(Sec. 3804, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished.❑ BUILDING.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS t0 �02
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY • r G'
Date AppliSant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 6 CROSS ST.
COMPENSATION INSURANCE SHOWERG Q OWNER
This section need not be completed if the work involved b 6 y MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner 1. SINK 6 CITY
t TEL.NO.
so as to become subject to the Workerso ensation Laws. DISHWASHER '
6 16 CONTRACTOR
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Date�"g'�-®3rt_Applicant CLOTHES WASHER 6100 ADDRESS Q O aKJ `I DEVI
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you'should become subject to. the Workers' CITYIJE,NO..-7/4/
Compensation provisions of the Labor Code, you must forth-
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER D LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 5t �(
(commencing with Section 7000)of Division 3 of the Business CUTLETS OVER Q0
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINA V LIDATION
lah
License Number Lic. Class f1i✓ j - 00 DATE fel
FIN C
Contractor Date B.
❑ W
I am exempt under Sec. d
B.BP.C. for this reason
Plan check fee
Signature Date: PLUMBING PERMIT ISSUING FEE$ 5 ;967 a 2A
• I 11015V TOTAL FEE
Plan check applicant # 0 0 0 0 0 5
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name I o.109.50
I hereby affirm that I am exempt from the Contractor's License Address 0 0 10 9.5 0 5
Law for-the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. 0 3 2 0 x 8 7
❑ I, as owner of the property,.will do the work and the
structure is not intended or offered for sale (Section ,
7044, Business and Professions Code).
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 01111.above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
A�anoon propert f r inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
'signature of Permittee Date