HomeMy Public PortalAbout6146 RENO AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION /APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consent to self in- 26DPW 4/90
sure,"a certificate of Workers'Compensation Insurance,ora 7GA6676ti7A
certified copy th r ec.f 3800, Lab. )
Compa COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy 141 e
❑. Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) gDDRESS
ertified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM (d FEE
de artment.
LOCALITY
Date � Applicant t. WATER CLOSET(TOILET) NEAREST
BATH TUB CROSS ST.
CERTIFICATE OF EXEM ROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed If the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS • A=
I certify that in the performance of the work for which this per- SINK CITY `� TEL.NO� `
mit is issued, I shall not employ any person in any manner so
aAl
as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS e
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR 40
emption,you should become subject to the Workers'Compen- CITY TEL.NO. �/
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. ,._g; CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSEb BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER v O
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL
fect. VALIDATION
HOSE BIB >
. DATE �-�-�,�
License Number Lic. Class _ 12
D FINAL P 4 C
��•! CTo4
Contracto a BY C
I am exempt under Sec. 3303 43.40 t
B.&P.C. for this reason Plan check fee
Date: TOTAL ITE 3 o 4r4
PLUMBING PERMIT ISSUING FEE$ Lo - J1113
Sig ure TOTAL FEE
SINGLE FAMILY CYMOD11 Aq) We
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name
Low for the following reason (Section 7031.5, Business and
Professions Code): Address
1., 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).
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 ►
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
above-mentioned property for inspe ion purposes.
,� � SEE REVERSE FOR EXPLANATORY LANGUAGE
i ature of Permittee Date