HomeMy Public PortalAbout6362 TRELAWNEY AVE_Plumbing__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 7yN67A
insure or a certificate of Workers Compensation Insurance CE 817(REV 10/81)
or a certified copy thereof (Sec 38DO Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
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copy is hereby furnished w Bl11lDING
Cert
FOR APPLICANT 70 FILL IN(PRIM OR TYPE) 2 L4h/NFY 97
tified opy is filed county budding mspec ADDRESS T
hon m t NUMBER FIXTURE OR ITEM LOG4LI17 (1
lirPG� {.� / 7
Date Appa11
n WATER 05ET NEAREST
CERTIFICATE OF EXEM ION F KERS BATH TUB CROSS ST OL�M�I
COMPENSATI ANCE SHOWER
(This section need not be comptoted R the wrw
work iolved by
the permit Is for one hundred dollars($100)or loss ) MAIL
LAvnioav ADDRESS• ` w .
1 certify that in the performance of the work for which this -. ..
permit is issued 1 shall not employ any person in any manner SINK CITY . ` TEL NO
so as to become subject to the Workers'Compensohon Laws DISHWASHER — `� �.4�
CONTRACT ,—f ./IWAs y Nwi
Date Arpl icont CLOTHESWASHER AOORESS
NOTICE TO APPLICANT If after making this Certificate of 61 41
SWIMMIr4G POOL RECEPTOR
Exemption you should became subject to the Workers CITY �o��1� m
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE C LIC
deemed revoked WATER HEATER LICENSE NO �7� ��> CLASS 14 +
LICENSED CONTRACTORS DECLARATION DISTRICT NO BV 1
I hereby off Inn,that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7OD0)of Division 3 of the Business
OUTLETS OVER �0 Y
and Professions Cade,and my license rs in full force and effect 15 PER SYSTEM
JDATE VALIDATION0
License Number Lic Class—
FI
lassV
INAContractor Date V 0
❑ I am exempt under Sec 10d
B&P C for this reason =
Plan check fee
Date PLUMBING PERMIT ISSUING FEES Q
Signature ;13188A
TOTAL FEE
Plan check applicant # 90 * 005
SINGLE FAMILY 1 • e 1 h 5 0
HOME OWNER BUILDER DECLARATION Nome
1 hereby affirm that i am exempt from the Contractor s License Address s Pf�ti1s/T V�✓��
Law for the following reason (Section 7031 5, Business and
Professions Code) City Tel No see 16505
13j, as owner of the property, will do the work and the
structure is not intended or offered for sole (Section ► 1 Q 16 -85
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec 3097, Gv C )
Lender s Nome
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 laws regulating Plumbing, and hereby
gre,pesentatives of this County to enter up the1iproperty ormspSEE REVERSE FOR EXPLANATORY LANGUAGE
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