HomeMy Public PortalAbout6336 TRELAWNEY AVE_Plumbing_10/16/1985_water line WORKER OMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby offu r I have a certificate of consent to self 76AWA
insure, or a rti hcate of Workers'Compemahon Insurance a 817(REV I0/81)
or a cernf copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
oli o Company
Cenified copy Is h f ed
❑ Certifi d is ith FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING r/
eic, N ding inspx ADORES$ GG.IQ wNE
ha NUMBER FIXTURE OR ITEM ® FEE
Locum QLE Cl y
Data qpp n WATER CLOSET NEAREST
CERTIFICATE OF EXEMPT] ROM WORKERS' BATH TUB CROSS ST D
COMPENSATION INSURANCE SHOWEROWNER
(This aeNoe cneed not be completed R Mork ork Involved by
MAIL
the permit Is far a"hundred dollars($100)or leas ) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner SINK CRY TEL NO
so as to become subject to the Workers Compensation Laws DISHWASHER
C0NTMACTOR — JAS N0v1c°1_1
Date T If aft CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making this the Ware of SWIMMING POOL RECEPTOR
Exemption you should become subject to the Worker CRY eP449/f TEL
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Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM FLLG-H f`/ r+�Y�� O
with comply with such provisions or this permit shall be STATE .�/ LLC
deemed revoked WATER HEATER LICENSE NO U CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO,i SSED V
I hereby offthat I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS V/JUY
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL VALI ATION d
License Number Lic Class DATE ' Iv V
00 FIN cc
Contractor Date BY40P 0
❑ I am exempt under Sec
B 8P C for this reason N
Date
Plan check fee Z
PLUMBING PERMIT ISSUING FEE$ � �31 9 1 A
Signature
TOTAL FEEwa— AV
{ • • • • • 5
SINGLE FAMILY Plan check applicant 1 • • 1 5 5 0
HOME OWNER-BUILDER DECLARATION Name. .74CJG UVQ wAzEQ er,
1 hereby affirm that I am exempt from the Contractor s License • • • 1 6 5 0 5
Law for the following reason (Section 7031 5, Business and Address37L5 S. AJ0UA1r411V V16W
Professions Code) city A4510494SQ4 Tel No7jN8 I Q 16 a.$5
❑ 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section ,
7044 Business and Professions Cade)
CONSTRUCTION LENDING AGENCY r
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 )
Lenders Name
Lender's Address
I certify that 1 hove read this application and state that the ►
above information is correct I agree to comply with all County
Ancnd Statelaws regulatinPlumbing, and hmebypresentaovea ofthioCd proerlyfarnspecSEE REVERSE FOR EXPLANATORY LANGUAGE
a Dote