HomeMy Public PortalAbout5028 ARDEN DR_Plumbing__ WORKFtS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
Iv hersb6fir�?i that I have a certificate of consent to self 76A667A
it insure or certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No��-)341Z Company �741tT� �7i��
Certifie$:copy is hereby furnished.
' FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
® Certified copy is filed with the.county building inspec- ADDRESS sz-La AeV"5;,./
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY C
Date �6 �Applicant ! ��5�� WATER CLOSET NEAREST
CERTIFICATE OP EXEMPTION FROM WORKERS' BATH TUB CROSS ST. LO4,✓An1-
COMPENSATIT INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER �— 6 t SC/Z
the permit is for one hundred dollars ($100)or less.) 8 _� MAIL
I certify that in the performance of the work for which this LAVATORY ADDRESS 1514mic
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO.A V�„,3 ¢eh
so as to become subject to the Workers'Compensation Laws. DISHWASHER 7 T�
CONTRACTOR _Z—3 �6,--S7
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS/a 7 /L f
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY zAy-V-dS TEL. NO. 5:?Z6 siz
with comply with such provisions or this permit shall be STATELIC.
deemed revoked. WATER HEATER LICENSE NO. Z�r7Z CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. POC SED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER (•/d �,
and Professions Code,and my license is in full force an effect. 0 51}40%155 `� DATE . VALIDAt_ION 0
License Number 2cJ Lic. Class
Date FINAL
Contractor Date BY
o
F-1I am exempt under Sec. 1 961 A
BAP.C. for this reason Plan check fee ,
Date: PLUMBING PERMIT ISSUING FEE$ I 0 940.50
Signature
TOTAL FEE 1 4105-6 00040,5005
Plan check applicant
SINGLE FAMILY 05,01 —$5
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
❑ I, 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 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
authorize representatives of this County to enter upon the
above-mentioned pro erty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consent to self in- 20-0026 DPW 4/90
76A667A
sure,or a pertifrYate of Workers'Compensation Insurance,or a
certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the.county building inspection ADDRESS
department: NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant WATER CLOSET(TOILET) NEAREST 0
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER
SHOWER
(This section need not be completed if the work involved by MAIL n�
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK CITY f �h TEL. NO.
mit is issued, I shall not employ any person in any manner so
as to become subject to the Workers' Compensation Laws. DISHWASHER
// CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the.Workers'Compen- CITY TEL. NO.
cation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER !/
and Professions Code, and my license is in.full force and ef- 5 PER SYSTEM FINAL VALIDATION
fect. HOSE BIB DATE — >-
License Number Lic. Class 9L
FINAL 5 O
U
Contractor Date BY ACCT.14 0
I am exempt under Sec.
3303 43°400
B.BP.C. for this reason 1.1
Plan check fee , 1 ITEMS W
Date: PLUMBING PERMIT ISSUING FEE$ TI)TAL43. 40-5
Sinature TOTAL FEE
D CHECK 43.40
SINGLE FAMILY applicant Plan check a
HOME OWNER-BUILDER DECLARATION PPP CHANGE n00
I hereby affirm that I am.exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and
Professions Code): Address 00001-0001 1/11!96
LNJ " as owner of the property, will do the work and the City Tel. No. 4218 1 AN 9:30
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 Address
1 certify that I have read this application and state that the pop.above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-me ' ed property f inspection purposes.
nt
A �^ 1(::yK SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date