HomeMy Public PortalAbout5833 RENO AVE_Plumbing__ WORKERS'COMPENSATION DECLARkl3w APPLICATION FOR PLUMBING PERMIT
17lereby affirm that I have a certifIcote-of Fonsent to self 20-0026 DPW 6/87
insure, or a certificate of Workers'Compd'isdiibn 'f%surance,, 76A667A
Or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Policy No. Company y iA_IA )f.s A/It> '
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ' 4 N 6
10 Certified copy is filed with the county building inspec- ADDRESS J
tion department. �+ NUMBER FIXTURE OR ITEM @ FEE
��2 9G KA /7 � . r WATER CLOSET �� LOCALITY ��R�� C f T��
Date Appl igant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' r BATHTUB CROSS ST.
COMPENSATION INSURANCE ( SHOWEROWNER hQr ZvN2 A
(This section need not be completed if the work Involved by
the permit is for one hundred dollars($100)or less.) LAVATORY MAIL
I certify that in the performance of the work for which this / '� ADDRESS )3b�/L
permit is issued,I shall not employ any person in any manner SINK CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR EiiWL'2�3%. (3�!X$E"2 S
Date Applicant ( CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of � s e r1 v9 y�.L O w lc/Z
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY ,in C A b t' TEL. NO.44 7-6/1-79
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM
STATE7 LIC. 1
deemed revoked. � WATER HEATER �- LICENSE NO. SI � 3 CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCE ED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 0
y Q� /
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL / VALIDATION >>
License Number .�.�7I�3 Lic. Class DATE ,Z 0
C3
�}
Contractor fro k'/r Nk��r 1' D�Date G 2 r / b FINAL
� O
❑ ~
1 am exempt under Sec. t]
W
B.AP.C. for this reason Il
Plan check fee W
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
SINGLE FAMILY
Plan check applicant C
—
HOME OWNER-BUILDER DECLARATION Name Ahs
;CTe
Ihereby affirm that I am exempt from the Contractor's License Address .': '' 65 �11
a
Law for the following reason (Section 7031.5, Business and u�1�!
Professions Code): City Tel. No. i ITEMS
EMS
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section ® T I'�(AL 6--35 a 50
7044, Business and Professions Code). CHECK 65.511
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CHANGE .013
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name 6/1/90
Lender's Address 1/32 AM '79.41
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 polo
authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
10
Signature of Permittee Date