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Home My Public Portal About4910 ARDSLEY DR_Plumbing__ WORKERS'COMPENSATION DECLICRATKSN 76A667F I hereby affirm that I have a certificate of content to „elf CE 617 (2-80)- 'APPLICATION FOR PLUMBING P E R M I T insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.) "fl w�l�l �� COUNTY OF LOS ANGELES BUILDING AND SAFETY wa. rub of Policy No.� ompany �!�— IxCertified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ❑ ADDRESS (O gfJE Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE department. LOCALITY CITY If- Date Applicant / WATER CLOSET NEAREST C.Mr BATH TUB CROSS ST. pLr G E• CERTIFICATE OF EXEMPTION FROM WORKERS' SHOWER OWNER COMPENSATION INSURANCE �� LAVATORY pd MAIL >_ (This section need not be completed if the work involved ADDRESS by the permit is for one hundred dollars ($100) or less.) SINK O CITY TEL. NO. U I certify that in the performance of the work for which this DISHWASHER W permit is issued, I shall not employ any person in any manner CONTRACTOR L O so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER ADDRESS 1.3gr iv, V LUU Date Applicant SWIMMING POOL RECEPTOR Il NOTICE TO APPLICANT: If, after making this Certificate of CITY�/� C0 A TEL. NO.� (� Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. Z Compensation provisions of the Labor Code, you must forth- LICENSE NO. CLASS with comply with such provisions or this permit shall be WATER HEATER deemed revoked. GAS SYSTEM OUTLETS r DIS RICT NO. PROCESSED BY LICENSED CONTRACTORS DECLARATION OUTLETS OVER I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000)of Division 3 of the Busi- FINAL `�_ VALIDATION ness and Professions Code, and my license is in full force and DATE effect. 1q5 FINAL �1 License Numbern_1eeJ,,..-I,w✓ (Lic.Class 6-1 BY Contractor�'AAtD IDY/Y/W Date I am exempt from the licensing requirements as I am a Plan check fee / licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ Q acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE o Lic.or Reg.No. Date Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's Address License Law for the following reascn (Section.7031.5, Busi- Tel.No. ness and Professions Code): ElI, as owner of the property, am exclusively contracting with licensed contractors to construct the project �:4 1 `�8 A (Section 7044, Business and Professions Code). # o00oo5 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency 2 2 a,5 0 for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). 0 0 0 24505 Lender's Name 0528-82 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 SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-m ned propert for inspection purposes. 5/2-7/P= Z ignature of Per it a ate WORKER'S COMPENSATION DECLARATION 26DPW9/89 76A6APPLICATION FOR PLUMBING PERMIT 76A667A I hereby,affirm,that I have a certificate of consent to self insure, or a certificata"of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab.C.) Policy No. Company��7✓� �� ' lam' COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. ❑ Certified copy is hereby furnished. BUILDING EJCertifiedcopy is filed with the county building inspection FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 'department. � NUMBER FIXTURE OR ITEM Q FEE LOCALITY Date �/��• V r4 1,'A licant ✓� ��L �__ pp WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS EST. COMPENSATION INSURANCE 1ASSESSOR MAP BOOK PAGE PARCEL (This section need not be completed if the work involved by the SHOWER r permit is for one hundred dollars($100)or less.) OWNERrJ I certify that in the performance of the work for which this permit LAVATORY ' is issued, I shall not employ any person in any manner so as toMAIL (—G,- become subject to the Workers' Compensation Laws. SINK ADDRESS DISWASHER CITY TEL.NO. Date Applicant CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT: If, after making this Certificate of C/ii C /�'�✓ f�� 'L Exemption, you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS I/— 7 provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY Ga TEL.NO.a Gs I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER �"&� (commencingwith Section 7000 of Division 3 of the Business and STATE (� / LIC. ,? 0 Professions Code,and my license is in full force and effect. ! GAS SYSTEM OUTLETS LICENSE NO. 1 G, ��0 CLASS &J r 0 OUTLETS OVER DISTRICT NO. PROCESSED BY cc 5 PER SYSTEM , License Number v Lic.Class l3 � DATE � � FINAL/2, VALIDATION W _ C'L-fLCL Contractor G!�� Date L�- � U F-1I am exempt under Sec. BY AL �,� B.&P.C.for this reason 4� Plan check fee ' Signature Date: PLUMBING PERMIT ISSUING FEE$ / -- ❑ TOTAL FEE D _ �3 Plan check applicant SINGLE FAMILY A;C'T t HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law 71 7 �#F for the following reason (Section 7031.5, Business and Professions Address Code): i�'� ��' City Tel. No. I - ❑ I,as owner of the property,will do the work and the structure y;# y{ 20 = 50 is not intended or offered for sale (Section 7044, Business �( and Professions Code). ' CHECK 2111.5E0 ��gSwt CONSTRUCTION LENDING AGENCY ;. I ,L3 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.) ClC){,#r#—_I[�r# -9-15 .i w,_ Lender's Name L•'y'.,t ; w,, 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ...,, WORKERS'COMPENSATION DECLARATION a APPLICATION FOR PLUMBING PERMIT I kereby affirm that I have a certificate of ,,ansi4 to 20-0026 DPW 6/87 +,re, or a,certificate of Workers' Compensation Insurance, 76A667A or:a.,:=rNfied copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS (f .. , . Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec- ADDRESS tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY WATER CLOSET Date Applicant r ��/ `� NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE OWNER (This section need not be completed if the work involved by SHOWER OF AIL 37 the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO. so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Date a �AppIicant Zia, CLOTHES CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of, Y I hlbbhWkADDRESS Exemption, you should become subject to the Workers' SWIMMING FOOL RECEPTOR P TEL. NO. CITY S /� 3 Compensation provisions of the Labor Code, you must forth- J" LAWN SPRINKLER SYSTEM !' i l with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. t CLASS LICENSED CONTRACTORS DECLARATION GAS SYSTEM OUTLETS DISTRI(T t�0. ROCES BY I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL V` D ATION ELI �r _g?_ , / DATE License Number `tfJ Lic. Class _ 00. FINAL % " T/ M Contractor � r.. .��-� Date v BY Q ❑ I am exempt under Sec. 0 LLK B.BP.C. for this reason Plan check feed100. Date: � PLUMBING PERMIT ISSUING FEE$ Signatur � Iv TOTAL FEE j} 5 Plan check applicant a SINGLE FAMILY ACCT°g HOME OWNER-BUILDER DECLARATION Name 1 hereby affirm that I am exempt from the Contractor's License 3307 ° ! Law for the following reason (Section 7031.5, Business and Address 1 ITEC Professions Code): City Tel. No. _ 5® _.�t� ❑ 1, as owner of the property, will do the work and the T!.lA� a structure is not intended or offered for sale (Section , CHECK 3=°50 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CHANGE °[!`! 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.). 13000-0001 10/ 13/90 Lender's Name 3096 1 Aid .1:46 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date