HomeMy Public PortalAbout6342 TRELAWNEY AVE_Plumbing_10/16/1985_water line WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
mSUre or a certificate of Workers Compensation Insurance CE 817(REV 10/81)
or a certified copy th eof (Sec 380D Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
CeRCOMPENSA
s her by furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BDADDRI� /L 7 L�WEy 5 r
spn filed t building inspec- �O
honI NUMBER FIXTURE OR ITEM ® FEE /� �,,/
LOCAun
DateA WATER CLOSETNEARES - L,�A
OF t0 RKERS' BATH TUB CROSS ST OLEO—/A
I URANCE OWNER
(This section reed not be completed If the work Involved by MAIL
SHOWER
the permit is for one hundred dollop($100)or less ) LAVATORY ADDRESS L _ T,
_
I certify that in the performance of the work for which this -
permit is issued, I shall not employ any person to any manner SINK CITY TEL NO
so as to become subject to the Workers Compensation Lave
DISHWASHER CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making this Certificate of
Exemption, you should become subject to the Workers SWIMMING POOL RECEPTOR TEL�/�Q^
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY ��� 7Y19
with comply with such provisions or this permit shall be STATE —yT q/t LIC
deemed revoked WATER HEATER LICF6E NO ;v 0 .7
LICENSED CONTRACTORS DECLARATION DISTRICT By
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER V UV y
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL V (DATION
DATE — r O
License Number be Class W
FINAL 1:19BY Q
Date ate sss0LLL
❑ I am exempt under Sec M
B 8P C for this reason
Plan check fee =
Date
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE V6 .5y
Plan check applicant
SINGLE FAMILY �' �s ;231 9.2 A
HOME OWNER-BUILDER DECLARATION Nome- PAS7�JL� L.vr7� M
I hereby affirm that I am exempt from the Contractor s License ��q� # • • • • • 5
Law for the following reason (Section 7031 5 Business and Addreu3 Z �_ eo //• l"
Professtons Code) City Tel No—;95& ( e • 1 6 5 Q
❑ I m owner of the property, will do the work and the ,
structure is not intended or offered far sole (Section
7041, Business and Professions Code) • e v 1 6505
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work fa which this permit is issued 1 Q 16-85
(Sec 3D97 Civ C )
Lender s Name
Lender s Address
1 certify that I have read this application and state that the ,
above information is correct I agree to comply with all County
4o,rdmis and Statelawsregulreprenbhves of thisironed propertyforinspection purSEE REVERSE FOR EXPLANATORY LANGUAGE
rm. to