HomeMy Public PortalAbout5703 OAK AVE_Plumbing_6/15/1987_. , "W(kKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I h0eby, affirm that I have a certificate of consent to self 76AS67A
insure, or a certificate of Workers' Compensation Insurance, CE 817 IFIEV. 8/86) L�
v or a certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN (PRINT OR TYPE) ADDRESS
Certified copy is filed with the county building inspec- n t
tion department. NUMBER FIXTURE OR ITEM ® FEE` 'l LOCALITY •� _ � �f
Date AppliSan tP-o / WATER CLOSET I('!1 v (NEAREST r ✓�"r/�/GJ{� /
CERT�F EXEMPT10 FROM WORKERS' BATHTUB CROSS ST.q ,�. �, ,�,,, /''" / //��
COMPENSATION INSURANCE IIIUr(I +OWNER}1_V •�'//Lr-.�� .T"^'CiCiO
(This section need not be completed if the work Involved by SHOWER
the permit is for one hundred dollars ($100) or less.) I LAVATORY MAIL
ADDRESS ( / / 6117
I certify that in the performance of the work for which this
permit is issued, 1 shall not employ any person in any manner I SINK CITY t TEL. N4/ 3r 99 y a
so as to become subject to the Workers' Compensation Laws. I DISHWASHER`
CONTRACTO
Dot- Applicant I CLOTHES WASHER ADDRESSqq z,.//
NOTICE TO APPLICANT: If, after making this Certificate of I //Y�, llgYi..war Q.rfC
Exemption, you should become subject to the Workers' I SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- I LAWN SPRINKLER SYSTEM I I ' CITY � .O i� fs TEL. NOrZS-z —�7j4
with comply with such provisions or this, permit shall be s7A E .�^ - r !! LIC /'.v
deemed revoked. (WATER HEATER (LICENSE NO49�� J ��71a CLA�j@ '�j ��/
LICENSED CONTRACTORS DECLARATION D(STR,q NOO.. PRgC ED B�
I hereby affirm that I am licensed under provisions of Chapter 9 I GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business I OUTLETS OVER L ��[
and Professions Code,,, and my license is in full force and effect. 5 PER SYSTEM FINAL VALID4TION
License Numb�e�,j//D/���/^,//��/_4 Lic Clas��'Cr �G� %f I
DATE
Contract 140— CJ_4 _Date I ( I I ddy
❑ 1 am exempt%under Sec. I I I I ` < 7 2 4 9 A
B.BP.C. for this reason
Plan check fee Poo.
tT�te; # . . s • e 5
Signature PLUMBING PERMIT ISSUING FEE $ I /Q �% I s e 2 a 5 0
TOTAL FEE
Plan check applicant °•• 2 a 5 0 5
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION Name o 6 l 5-87
1 hereby affirm that I am exempt from the Contractor's License Address
Low for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
❑ 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 Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there iso construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lenders Nam -
Lender's Address
I certify that I hoe read this application and state that the
0101.
above inform i is correct. I agree to comply with all County
ordinances tate laws regulating Plumbing, and hereby
authorizer r _motives of this County to anter upon the
above- property or ins urposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Ail k
Signature of Permittee Date
N> a c
O N N 0 o
Z N N D
411
N O . m
P. < ry S P _. O C ❑
m-0 to � n O ° T p V n� C-
d,wm<o"ago'°�_°N
<
- 0 3
o
a;
a ��
mOg�a0�m�
�o.pm �mm'S$oom-
m
o ] Mx n
]
� �mO.�m%°°a
'
mo. <��•o n<oo
nm'i
zo
z
_
ir
CL
c
O u g n o
3
�.
p
fi n
°' T O O n° ]
m� 0 m m S m �?
•