HomeMy Public PortalAbout6334 TRELAWNEY AVE_Plumbing_10/16/1985_water line WORKERS COMPENSATIONDECLARATION
of once APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate o4 convent to self 76g667q
ms,ure, or d certificate of Workers'Compensation Insurance, CE 817(REV 10/81)
w a certified co ereof (Sec 3 Xq tab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
P cY Compony
94.�Cenfiiscl copy to hereby f
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certib cop s filed with o ry g Lnssp-�:c- ADDRESS
ho rt tit NUMBER FIXTURE OR ITEM ® FEE LOCAUTr7,_r:,f4AT_.' Q
V 7le-
Dote Appltga WATER CLOSET NEAREST
TIF CATE OF EXEMPT ERS BATH TUB CROSS ST
COMPENSATION I CE OWNER
(This section need rat be completed if the work hnelved by SHOWER
the permit is for one hundred dollars($100)or loss) MAIL
I certify that in the performance of the work for which this LAVATORY ADDRESS,
permit a issued, I shall not employ any person in any monner SINK CITY - TEL NO
w as to become wbiect to the Workers Compensation Lows DISHWASHER CONT1ZAROR0"AW yAf^VV/ea�
Dote Applicant CLOTHES WASHER ADD Kaff
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NOTICE TO APPLICANT If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become sublect to the Workers /,p�� p
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY " "�� TEL NC}�(��B
with comply with such provisions or this Permit shall be STATE �-}�s LIC
deemed revoked WATER HEATER 110ENSE NO J/V �/ CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO,ri BY
I hereby offmm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (//)(,J(
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is in full force and effect S PER SYSTEM >
FINAL
ON VALIDATION C
ATE
License Number Lic Clow V
FIN cc
Contractor Dote BY 0
❑ 1 am exempt under Sec rid
B 8P C for this reason —4 31 7,4 A N
Plan check fee ?
Dote PLUMBING PERMIT ISSUING FEE S # e s s s s 5
Signature
TOTAL FEE I • it 16650
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name (414 B/P CU, e e e 1 6 5 0£S
I hereby affirm that I am exempt from the Controctor's License
Law for Address the following reason (Section 7031 5, Business and 3725 AE- /L/Qy! Ti��ik-� f���W 1 0 1 6—8 5
Professions Code) City P,475.4 A Tel No
❑
1' 05
owner of the property will do the work and the
structure is not intended or offered for sale (Section Poo
Business and Professions Code)
CONSTRUCTION LENDING AGENCY
I hereby affirm that there iso construction lending agency for r
the performance of the work for which this permit is issued
(Sec 3097 Ov C )
Lender's Name
Lender s AAOdrm
I cenify that I have rood this application and state that the ►
l» a mformahon a carted I agree to comply with all County
r nd State laws regulating Plumbing and he eby
a hor ntotivea of this County to enter u the
ed property for mspechon purp es
SEE REVERSE FOR EXPLANATORY LANGUAGE
Dote