HomeMy Public PortalAbout6222 RENO AVE_Plumbing__ WORKERS'C04VIPENSATIONDECLARATION j' APPLIcATI®N FOR PLUMBING PERMIT
F.I?herel�y affirm that I}gave a certificate of consent to self 76A6¢7A ,
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insure, or a certificate of Workers'Compensation Insurance, .CE 817(REV. 10/81)
or q certified cop?thereof(Sec. 3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
FEM
Policy No. ,
Company
Certified copy is hereby furnished. BUILDING y9 ,�!
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS �i �iZX
Certified copy is filed with fh. county build' g inspec-
tion department. NUMBER FIXTURE OR ITEM. @ FEE LOCALITY
WATER CLOSET f •��
Date Appli4ant NEAREST
CERTIFICATE OF EXEMPTION#kOM W ERS' BATH TUB CROSS$T. AW Q
COMPENSATION INSURANCE
SHOWER OWNER �. 1
(This section need not be completed if the work involved by MAIL
the permit Is for one hundreddollars($100)or less.) r LAVATORY ADDRESS 12 :
1 certify that in the performance-of the work for which this a
permit is issued, I shall not employ any person in any manner SINK CITY
so as to become subject to the Workers'Compensation Laws. DISHWASHER '
CONTRACTOR
Date —Applicant CLOTHES WASHER. i
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS ®� Si � Al�
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE IC.
deemed revoked.. WATER HEATER ® LICENSE NO. 7— CLASS
LICENSED CONTRACTORS DECLARATION DISTRICTy O. P SSED BY
VE` (J�t
I hereby affirm that lam licensed under GAS SYSTEM OUTLETS.der provisions of Chapter 9 ! ® >
(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 1 VALIDAT N
' ,i� v
License Nu er DATE Lic. Class U
FINAL i Cl
Contractor Date BY
❑ I am a mpt and Sec. t C�
B.BP.C. for this reason Plan check fee ;91 1 a 3 A Z
Date: t PLUMBING PERMIT ISSUING FEE
Signature ^ ,
TOTAL FEE 0 6-V o 0 04(1509
1' Plan check applicant '1206-84
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
-Professions Code): Cit '
y Tel. No.
❑ 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section I
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.). j
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 Co my to enter upon the
above-mentioned property for ins p ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee to