HomeMy Public PortalAbout6142 RENO AVE_Plumbing__ ' WORKERS'COMPENSATION DECLARATION APPLOCA 00N FOR PLUMBING PER OT
I l2eraby.oASirm that I have a certificate of consent to self 20-0026 DPW 6/87
s insure, or a certificate of Workers'Compensation Insurance, 7GA667A
or,8 certified copy thereof (Sec. 3800, 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 I I Z `I y)Q
Certified copy is filed with the county building inspec- NUMBER FIXTURE OR ITEM @ FEE
tion department. LOCALITY
WATER CLOSET
Date Appl irant NEAREST dy
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER w
(This section nood not bo complotod If tho work involvod by
J SHOWER �>�
tho pormit Is for ono hundrod dollars($100)or loss.) ' LAVATORY MAIL
ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK ow CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER 6-i7
7 (� CONTRACTOR
Date I �� LApplicanty � UA54 I CLOTHES WASHER
NOTICE TO APPLICANT: If, of mak ng this&tertificate of ADDRESS
Exemption, you should bec a subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL. NO.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. (p PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS J.
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER 6 L'GL
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
DATEJ Q
License Number Lic. Class C3
FINA
Contractor Date BY
❑ I am exempt under Sec. tU
B.BP.C. for this reason ® � Z
Plan check fee / �{ /'
Date: PLUMBING PERMIT ISSUING FEE$ / F1CCLIM
Signature 111
g TOTAL FEE �f1, -� 33013 160.65
SINGLE FAMILY Plan check applicant 1 YTOS
HOME OWNER-BUILDER DECLARATION Name
TOTkL 1460 o 4S5
I hereby affirm that I am exempt from the Contractor's License Address 9r�{LG�► 1 ,)]0�4�
P1,
r the following reason (Section 7031.5, Business and
ions Code): City Tel. No. (BIDE .05
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). X,60-6001 5i26/93
CONSTRUCTION LENDING AGENCY ?51 1 AN 750
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
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize repre$entatives of this County to enter upon the
above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
9and S-2.G 3
Sig ' ture ofJR1rmittee Date