Loading...
HomeMy Public PortalAbout5703 OAK AVE_Plumbing_8/12/1987_,^, M(ORKERS' COMPENSATION DECLARATION T hereby, affirm that I have a certificate of consent to self 76A687A insure, or a certificate of Workers' Compensation Insurance, CE 817 (REV. 8/86) or a certified copy thereof (Sec. 3800, Lab. C.) Policy No.—Company ❑Certified copy is hereby furnished. Certified copy is filed with the county building Inspec- tion Jepartment� Date y y O Appl itant� CERTIFICATE OF EXEMPTION FROM ORKERS' COMPENSATION INSURANCE (This section need not be completed If the work Involved by the permit Is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Dat. Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Nu�}[�)h/er Y J 3 � Lic. Class 20 Contractarste vz ❑ I am exempt under Sec. B.BP.C. for this reason Date: Signatur- APPLICATION FOR PLUMBING PERMIT COUNTY OF LOS ANGELES FOR APPLICANT TO FILL IN (PRINT OR TYPE) NUMBER FIXTURE OR ITEM I Name WATER CLOSET BATH TUB Law for .the following reason (Section 7031.5, Business and SHOWER I` LAVATORY SINK ` DISHWASHER r CLOTHES WASHER SWIMMING POOL RECEPTOR LAWN SPRINKLER SYSTEM WATER HEATER GAS SYSTEM OUTLETS OUTLETS OVER 5 PER SYSTEM Plan check fee PLUMBING PERMIT ISSUING FEE $ TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER -BUILDER DECLARATION I Name I hereby affirm that I am exempt from the Contractor's License I Address Law for .the following reason (Section 7031.5, Business and Professions Code): I City ❑ 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 is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Addres- I certify that I have read this application and state that the above informati n i correct. agree to comply with all County ordinances an St to lows regulating Plumbing, and hereby authorize re s tatives of this Cc on the ab a -men o pection pure ses. �% v/ Signature of Permittee Da Tel. No. DEPT. OF PUBLIC WORKS CJI BUILDING f ©� ADDRESS-- FEE DDRESSFEE LOCALITY c•Gl / / // NEAREST CROSS ST. OWNER `I� '""– ��V�✓'" _ MAIL ADDRESS / if 6 Ofl/.) CI7Y 1[Yw r TEL. NO. O(/ CONTRACTO �ADDRESff�Q -/, 6?, //� �z� r^'. CITYVJ it _ i/�!/�` `^'—�. TEL. NOGG Z�IQ rSTATE LIC. LICENSE NO. CLASS DISTRICT NO PSS BY 51 Of FINADA EL /�6f �7 VAL ATION BI?V®./.��� L J (�► ;F7656A Slygeeeee5 1••2250 e e e 2 2 5 0 5 08.1287 SEE REVERSE FOR EXPLANATORY LANGUAGE N v y D C N r A 2 O D > < P C N OC O A t Z A N D ppC• GUN T1�a_3b 'rymU �Q'�n '�a°' ino-< o.: -on'=Js, =�« 0 3 `a; m • mry zz ono i.o� 6 F 0 • f V ^n s�'pp s'•^o vim a'v �:..°�.F.bcm�°3 Ui V --. b°3n'o n:v ° o.�e•w-mac r� c o °r� m (n AI A U O N v y D C N r A 2 O D > < P C N OC O A t Z A N D ppC• GUN T1�a_3b 'rymU �Q'�n '�a°' ino-< o.: -on'=Js, =�« 0 3 `a; m • mry zz ono i.o� 6 F 0 V ^n s�'pp s'•^o vim a'v �:..°�.F.bcm�°3 V --. b°3n'o n:v ° o.�e•w-mac r� c o °r� m (n A O , n 3 a o y Ci b 9 l ° N /•14' 7 i j L a. ry n [iG��, p4 ❑u�i ppC• GUN T1�a_3b 'rymU �Q'�n '�a°' ino-< o.: -on'=Js, =�« 0 3 `a; m • mry zz ono i.o� o ',� s�'pp s'•^o vim a'v �:..°�.F.bcm�°3 b°3n'o n:v ° o.�e•w-mac r� c o °r� m