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HomeMy Public PortalAbout6343 TRELAWNEY AVE_Plumbing__ DEC TION WORKERS'that CI have aATION cafe of corse APPLICATION FOR PLUMBING PERMIT I hereby aHum that I have a <endicale of consent to self 76A067A insure or a certificate of Workers Compensation Insurance CE 817(REV 10/81) or a Y4ertified copy thhe�rrLLe``ggI Sec 3800, lob C ) a COUNTY OF LOS ANGELES BUILDING AND SAFETY QiEy No 8 inpany )VxieAQIJT �A/al, l Certified copy is hereby furnished FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 3(/ i]� /1 i. .NG Certified copy is filed with the county building rroILDING 7 C /Ts'T/ tion de rt ant NUMBER FIXTURE OR ITEM ® FEE LOCALITY rLo/yf Lo �' Dote , / �6 AppliSant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST COMPENSATION INSURANCE SHOWER OWNERAz �Q NP/SO/� (This section nand not be wrttpleted If the work Involved by the permit Is for ane hundred dollars($100)cr less) LAVATORY MAIL ADDRESS J TtZ1P 144J/✓Co I certify that in the performance of the work for which this SINK CITY /�rT TEL NO'y _ /`8 permit is issued I shall not employ any person in any manner �/ so as to become subject to the Workers'Compensation Laws A DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER q NOTICE TO APPLICANT If, after making this Certificate of AppRE55 Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM Cltt 7e TEL NO with comply with such provisions or this permit shall be STATEY&3735 / ? LIC deemed revoked WATER HEATER LICENSE NO /&J 7 S CLASS C LICENSED CONTRACTORS DECLARATION DISTRICT NO D By 1 hereby off irm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETSY (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER ` d d and Profession Code and my license a in full force and effect 15 PER SYSTEM G/ o DATEL _ VALID ON u License Number • o�713`; LmClass e 13 O as FINC,0^/No 2 T/S S BY O Contractor Dote V ❑ I am exempt under Sec d N B 8P C for this reason Plan check fee Dote PLUMBING PERMIT ISSUING FEE$ Signature 5 0 5 5 A TOTAL FEE Plan check applicant # e e e a is 5 SINGLE FAMILY HOME OWNER BUILDER DECLARATION Name ) - - 1650 1 hereby affirm that I am exempt from the Contractor s License ,Address Low for the following reason (Section 7031 5 Business and a a e Q 5 0 Professions Code) City Tel No ❑ I, as owner of the property will do the work and the 0. 16-86 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 far 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 information is correct I agree to comply with all County ordinances and State jaws regulating Plumbing and hereby authorize representatives of this County to enter upon the above mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signotur of Permittee Date