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Home My Public Portal About4930 BALDWIN AVE_Plumbing__ (2) N 4 � WORKERS COM{ENSATION DECLARATION 76A667A I hereby affirm that I have a certificate of consent to self ce et 7 (Z 60) APPLICATION FOR PLUMBING PERMIT r insure or a certificate of Workers Compensation Insurance or i { a certified copy thereof(Sec 3800 Lab C) a ti COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company c r FJ Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING / ADDRESS Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE LOCALITY --- department � Date Applicant / WATER CLOSET / NEAREST BATH TUB CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS, SHOWER OWNER r COMPENSATION INSURANCE LAVATORY ° MAIL (This section need not be completed if the work involved v ADDRESS I } by the permit is for one hundred dollars ($100) or less) SINK - 0 z � CITY TEL NO �i p f V I certify that to the performance of the work for which this DISHWASHER � t permit+is issued I shall not employ any person in any manner r CONTRACTOR e so'as to become subject to the Workers Comp�tt n Laws CLOTHES WASHER O n ADDRESS S r Date Appltcant4P-41 � /J �� w�r� SWIMMING POOL RECEPTOR V NOTICE TO APPLICANT If after making this Certiftcate of CITY TEL NOLLJ Exemption you should become subject to the Workers LAWN SPRINKLER'SYSTEM STATE J LIC CL Compensation provisions of the Labor Code you must forth % WATER HEATER LICENSE NO / CL SS Z with comply with such provisions or this permit shall be deemed revoked GAS SYSTEM OUTLETS DISTRICTNO P OCES D Y LICENSED CONTRACTORS DECLARATION OUTLETS OVER 1 0 O I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Bust FINAL ` ;,y� VALIDA ISN ness and Professions Code and my license is in full force and ' DATE G. effect r FINAL � License Number Lic Class BY Contractor Date ; I ami`exempt from the licensing requirements as I am a Plan check fee 44-1-alc� licensed architect or a registered professional engmeer` PLUMBING PERMIT ISSUING FEE$ acting in my professional capacity (Section 7051 Bus '�� yam_ mess and Professions Code) TOTAL FEE z Lic or Reg No Date Plan check applicant HOME OWNER BUILDER DECLARATION Name , t Address I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 7031 5 Busi City Tel No i t ness and Professions Code) Y I as owner of the property am exclusively contracting with licensed contractors to construct the project (Section 7044 Business and Professions Code) y 2 3 5 9 6 A r CONSTRUCTION LENDING AGENCY F c # o o o o o 5 I hereby affirm that there is a construction lending agency a for the performance of the work for which this permit is ° 2�o 0 6 0 5 0 issued(Sec 3097 Civ C) e Lender s Name a o 0 o 6 0 5 0 55 Y 'n Lender s Addressr a0 a1 0 2.—8 1 � I certify that I have read this application and state that the above information is correct I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing and hereby w authorize representatives of this County to enter upon the above mentioned property for inspection purposes ignature of Permittee Date a a WORKERS' COMPENSATION DECLARATION20-0026 APPLICATION FOR PLUMBING PERMIT .. I hereb-y:, affirm that 1 have a ce'rtificat'e of consent to self in- 76A667A PW 4/87 /1 sure, or b certificate of Workers'Compensation Insurance,or a CE 817(REV-8/86) L,UI certified copy thereof (Sec: 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company Certified copy is hereby furnished. ` FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING Certified copy is filed with th'e county building inspection ADDRESS 'H3 O �ti I win f/� NUMBER FIXTURE OR ITEM LOCALITY • department. @ FEE DateApplicant WATER CLOSET(TOILET) NEAREST / e i le e,'X CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. N a i,f T. 4'p al e r z 4f Z--1 COMPENSATION INSURANCE ! SHOWER OWNER 3 a;a (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS 93 11/r"� ' ele I certify that in the performance of the work for which this per- SINK mit is issued, I shall not employ any person in any manner so CITY j/� �I''� TEL. NO. as to'become subject to the Workers mpensa ' n Laws DISHWASHER r` CONTRACTOR Date !� Applicant CLOTHES WASHER ADDRESS' NOTICE TO APPLICANT: If, after maki this Certifi o Ex- _ SWIMMING POOL RECEPTOR emption, you should become subject to the Workers Compen- CITY TEL. NO. sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS'DECLARATION DISTRICT NO. PR CESSED�Y I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS , 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATIO fect. DATE 17 O License Number Lic. Class V FI L 0 Contractor Date p ElI am exempt under Sec. B.&P.C. for this reason Plan check fee ® � �f Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE 0 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name Low for the following reason (Section 7031.5, Business and Professions Code): Address ® I, as owner of the property, will do.the work and the City Tel. No. ;2 9 1 2,9'A structure is not intended or offered for sale(Section 7044, # 0 0 0 o ao 5 Business and Professions Code). CONSTRUCTION LENDING AGENCY , ® d ° - 40.50 I hereby affirm that there is a construction lending agency for ° ° ° 4 0, 5.0 v the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Q a 0 8,`-, 8 8 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 laws regulating Plumbing, and hereby oil authorize representatives of this County to enter upon the abov entione ropert.y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sig ure of Permitte Date WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I*A rZby,'dM4 that I have a certificate of consent to self in- 76A667A PW n/87 n surd cir 4certificate of Workers'Compensation Insurance,ora CE 817(REV. 8/86) `lUl rcertified copy thefeof (Sec. 3800, Lab. C.) - ` COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 3 0 K8Q- y Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY T-c�,,, /� WATER CLOSET(TOILET) / Date Applicant O NEAREST ' CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. L 0 V✓e r z.ti COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK y5�`/`�OS mit is issued, I shall not employ any person in 6ny manner so CITY TEL. NO. 77�� as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Ex- emption,you should become subject to the Workers'Compen- CITY TEL. NO. sation provisions of the Labor Code, you'must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION >_ fect. DATE 2 CL O License Number Lic. Class FINAL ccV Contractor Date BY (V� O DI am exempt under Sec. 17 V f� B.&P.C. for this reason Plan check fee pop.Date: PLUMBING PERMIT ISSUING FEE$- /9-00 Signature TOTAL FEE SINGLE FAMILY plan check applicant HOME OWNER-BUILDER DECLARATION pp I hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and ACCT z e Professions Code):. Address 37 _si 3 as owner of the property, will.do the work and the City Tel. No. structure is not intended or offered for sale(Section 7044, - +- Business and Professions Code). ► ---�•i1 . j l{RL 8 3 CONSTRUCTION LENDING AGENCY CHECK i r 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 2/ 7!f f 4'i i. Ji Ii Lender's Address _t_4y.2 All �„•.,,_� 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 authorize represe tives of this County to enter upon the above- tione ropert for inspection purposes. oZ_7- SEE REVERSE FOR EXPLANATORY LANGUAGE Signatu of Permitte Date