HomeMy Public PortalAbout6229 RENO AVE_Plumbing__ W(')RKERS'COMPENSATION DECLARATION ALICAT� N FOR PLUMBING PERMIT
I here�y affirm that:il have a certificate of consent to self 20-0026 DPW 6/87
insure, br a certificate of Workers'Compensation Insurance, 76A667A
vor a certified copy the'r..eof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Policy No. '?aCompany
Certified copy is hereby furnished. e .
r_1FOR APPLICANT TO FILL IN(PRINT OR TYPE). BUILDING
Certified copy is filed with the county building inspec- ADDRESS /
tion department: NUMBER FIXTURE OR ITEM @ FEE. LOCALITY `
WATER CLOSET IV
Date Appli4ant NEAREST
I CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST: �•
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be eomple4ed If the work involved by IL
the permit is for one hundred dollar's($100)or less.) LAVATORY ADDRESS AY
I certify that in the performance. of the work for which this
permit is issued,I shall not employ any person in any manner SINK CITY G `' TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
yyy c
DateApplicant CLOTHES WASFIER ADDRESS. /a J
01
NOTICE TO P I ANT: If, after king this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should beco subject to the Workers' CITY TEL. NO. �. kl
s,
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM `
with comply with such provisions or this permit shall be STATE LIC. y
deemed revoked. WATER HEATER LICENSE NO. CLASS *,D
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby off irm•that I am licensed under provisions of'Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000.)of Division 3 of the Business OUTLETS OVER 4
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM DATE —7 — VALIDATION
License Numbei '� - Lic. Class G�� C;
-� FINAL / 12
Contractor (�°r � ' Date BY ^A C
❑ I am exempt under Sec.
LL
B.&P.C. for this reason Plan check fee Q
Date: PLUMBING PERMIT ISSUING FEE$
Signature `
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Liceps
Ww for the following reason (Section 7031.5, Business and Address
Professions Code): City Tel. No.• =-SI 7
❑ I, 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). a 1 2 0
CONSTRUCTION LENDING AGENCY
I hereby off irm 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 7
Lender's Address r3M� t
I ceitify 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"sentatives of this County to enter upon the
above-mentionedproperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
nature of Permittee Dat .