HomeMy Public PortalAbout6268 RENO AVE_Plumbing__ �ORKERS'COMPENSATION DECLARATION APPLICATION
k PPL IC/is TION F®® PLUMBING
® Il pApBIN PERMIT
T hereby, affirm that I have a certificate of consent to self in- 76A667APW 4/87 /"!1� L b/"'\ 9� A� 9L1�1�!/II® 6� PERMIT
e
sure,or a certificate pf Workgrs' ompensation Insurance,or a CE 817(REV.8/86)
cgrtified copyTtherdof(Sec. 380 , Lab. C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby furnished.
Certified co is filed with the count building p FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING / z6 f �D
copy� y gins inspection ADDRESS f�
department. NUMBER FIXTURE OR ITEM @ FEE
/ LOCALITY ��lw �f
Date Applicant WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 0 CROSS ST. S Q/f lJil/J //t/ l/f
COMPENSATION INSURANCE SHOWER O OWNER � ��t L L /J_7
(This section need not be completed if the work involved by MAIL
/
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS t'// -41O �. �v " ✓
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CITY• TEL. NO. d
as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR j, AZ_,10 /'
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption,you should become subject to the Workers'Compen- CITY TEL. NO.
safion provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PRO egsS D BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER t
fand
e t.Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VAo NTION a
DATE 0
License Number Lic. Class V
FINA
Contractor Date BYIeA, O
I am exempt under Sec. W
B.BP.C. for this reason W
Plan check fee ® 7 91.2 A Z
Date: PLUMBING PERMIT ISSUING FEE$
Signature #TOTAL FEE � o 0 0 0 0 5
SINGLE FAMILY Plan check a S I ° ° 2 a5 0
HOME OWNER-BUILDER DECLARATION applicant 0 0 0 2 a 5 0 5
I hereby affirm that I am exempt from the Contractor's License Name Z2�/V `. , /-/-_
Law for the following reason (Section 7031.5, Business and p
Professions Code): Address zl!5 s9 V
Cit Tel. No. 5-- o9, 14-87
I, as owner of the property, will do the work and the Y
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 informafio is correct. I agree to comply with all County
ordinances an tate laws regulating Plumbing, and hereby
authorize r esentatives of this County to enter upon the
above-m oned prozpty for inspection p poses.
�. 9 oSEE REVERSE FOR EXPLANATORY LANGUAGE,91
Signature ofrmittee Date