Loading...
HomeMy Public PortalAbout6336 TRELAWNEY AVE_Plumbing__ 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($100)or leas ) LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued I shall not employ any person in any manner SINK CRY TEL NO so as to become subject to the Workers Compensation Laws DISHWASHER C0NTMACTOR — JAS N0v1c°1_1 Date T If aft CLOTHES WASHER ADDRESS NOTICE TO APPLICANT If after making this the Ware of SWIMMING POOL RECEPTOR Exemption you should become subject to the Worker CRY eP449/f TEL ___,s�.,7�p Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM FLLG-H f`/ r+�Y�� O with comply with such provisions or this permit shall be STATE .�/ LLC deemed revoked WATER HEATER LICENSE NO U CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO,i SSED V I hereby offthat I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS V/JUY (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL VALI ATION d License Number Lic Class DATE ' Iv V 00 FIN cc Contractor Date BY40P 0 ❑ I am exempt under Sec B 8P C for this reason N Date Plan check fee Z PLUMBING PERMIT ISSUING FEE$ � �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