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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 .