HomeMy Public PortalAbout6003 RENO AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION
20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT
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I fidieby, affirm that I have a certificate of cgyisent to pelf in- 76A667A
sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV.8/86)
cerfJf,led copy thereof(Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company ,
Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS VV rA"Q
department. NUMBER FIXTURE OR ITEM @ FEE
p LOCALITY
10Date Applicant WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST. OL
COMPENSATION INSURANCE ( OWNER
SHOWER
(This section need not be completed if the work Involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS t2 Vt
1 certify that in the performance of the work for which this per
mit is issued, I shall not employ any person in any manner so SINK d CITY Ct TEL. NO.
as to become subject to the Workers'Compensation.Laws. C OOP
DISHWASHER
CONTRACTOR —
Date Applicant CLOTHES WASHER Q UVADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such-pro4is(ons or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION 5TRn1N0_,q ROCS BY
1 hereby affirm that I am licensed under provisions of Chapter GAS.SYSTEM OUTLETS (SJ(
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
fe d Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL /VALIDATION d
DATE -26..C� O
License Number Lic. Class V
FINAL
Contractor Date BY O
I am exempt under Sec.
B.BP.C. for this reason Plan check fee ► cc
Date: PLUMBING PERMIT ISSUING FEE$
Signature TOTAL FEE
SINGLE FAMILY Plan Check applicant
HOME OWNER-BUILDER DECLARATIONr
I hereby-affirm that I am exempt from the Contractor's License Name -5
(�/+.T
Law for the following reason (Section 7031.5, Business and ACC °V
Professions Code): Address
City
I,-as owner of the property, will do the work and the Y Tel. `x'507 58°190
No. -
structure is not intended or offered for sale(Section7O44, 1 ITM.S
Business and Professions Code). , TOTAL 058.51131
CONSTRUCTION LENDING-AGENCY CHECK °
I hereby affirm that there is a construction lending agency for
50
the performance of the work for which this permit-is issued ; CHANIGE °00
(Sec. 3097, Civ. C.).
Lender's Name 0000-0001 10/18/89
Lender's Address 6275 1 IN 8°337
1 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 -
authorize representatives of this County to enter upon the
abov morte�i-property fo inspection purposes.
./2 et_k � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Perm Date