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HomeMy Public PortalAbout6644 OAK AVE_Plumbing__ �+ y ORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING .PERMIT r Loffirrn-fho!.l have a certificate of consent to self in- 176A666 DPW 4/87 n�� 76A667A "5tl�ie, a certificate of Workers'Compensation Insurance,ora CE 817(REV.8/86) i certified copy thereof(Sec. 3800, Lab. C.) , Rolicy.No. ' Company, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS' ❑ 1 Certified copy is hereby furnished. I FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING / oak, [� Certified copy is filed with the county building.inspection ADDRESS b department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY �� �' I WATER CLOSET(TOILET) Tim He Date Applicant �ORKERS : i NEAREST CERTIFICATE OF EXEMPTI N FROM BATH TUB CROSS ST. COMPENSATION INSURANCE' SHOWER OWNER ,(This section need not be completed If the work involved by ,. -. - the permit Is for one hundred dollars($100)or less.), � I LAVATORY MAIL ADDRESS - �� �� �/' ' I certify that in the performance of the work for which this per- ` SINK mit is issued, I shall not employ any person in any manner so CITY•I TEL.NO. as to become subject to the Workers'Compensation Laws. ( DISHWASHER C� CONTRACTOR G DateApplicant I CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS 3o I i empfion;you should become subject CITY to the Workers' SWIMMING POOL RECEPTOR ComPen- I TEL. NO-38.7— sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM S e� ly witli:such provisions or this permit shall be deemed revok- STATE CLASS .8 ed: WATER,HEATER LICENSE NO... LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCESSED BY I hereby affirm that I-am licensed under provisions of Chapter GAS SYSTEM OUTLETS t7 © w —17-9(commencing with Section 7000)of Division of the Business OUTLETS OVER •' and Professions Code, and my-license is in full force and ef- &PER SYSTEM FINAL VALIDATIG feet. "' 1�2�8/f� Lic. Class 8 DAT �2 V 0 License Number O FIN Contracfo + Date �� 0 I BYE O I am exempt under Sec. I W B.&P.C. for this reason I a Plan check fee 5 Date' $ PLUMBING PERMIT ISSUING FEE$ Signature- �~ I TOTAL FEE ��(} SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan.check applicant I hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and Professions Code): F Address I, as owner of the property, will do-the work and the City Tel. No. structure is not intended or offered for sale(Section 7044, Business and Professions Code). P_8 b 7,5A CONSTRUCTION LENDING AGENCY # 000.005 I.hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued ( 0 0 2 a 5 0 (Sec. 3097;Civ. C.). • - o - 28:50It! Lender's Name 1229-87 Lender's Address I I certify that I have read this application and state that the ; above Information is correct.I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby .I authorize representatives of this County to enter upon the above-m tioned property for inspection purposes. > SEE REVERSE FOR EXPLANATORY LANGUAGE tSig re qJ01fermittee or Dfer