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Home My Public Portal About5319 BALDWIN AVE_Plumbing__ WORKER'S COMPENSATION DECLARATION 20.0026 DPW 9/89 APPLICATION FOR PLUMBING PERMIT 76A667A jy I heaffirm that I have a certificate of consent to self insure, or a cs¢r[iA14Pr of Worker's Compensation Insurance, or a certified copy Onereof(Sec. 3800 Lab.C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. 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 inspection ADDRESS ("( department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET' , 00NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB ss,, CROSS SL t COMPENSATION INSURANCE ✓ aU ASSESSOR T.R I (This section need not be completed if the work involved by the SHOWER U MAP BOOK PAGE PARCEL y permit is for one hundred dollars($100)or less.) L LAVATORY ©n OWNER 1 certify that in the performance of the work for which this permit Q is issued, I shall not employ any person in any manner so as to MAIL SINK ADDRESS Gt� lT)+ become subject to the Workers' Compensation Laws. DISWASHER CITY CC TEL.N04 q 1(-) Date Applicant CLOTHES WASHER Q CONTRACTOR T NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER a (commencingwith Section 7000 of Division 3 of the Business and STATE LIC. ) rnf V Professions Code, and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. CLASS OUTLETS OVER V DISTRICI NO. PROCESSED BY eD ci �` �� 5 PER SYSTEM G,I�Ti/ License Number Lic.Class I' DATI�l� VALIDATION IL Contractor Date Z ❑ FINA I am exempt under Sec. - � BY ✓� BAP.C.for this reason Date: Plan check fee , Signature PLUMBING PERMIT ISSUING FEE$ ❑ TOTAL FEE r., Plan check applicant ;<, ;,.;v,:!; SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Address f E ;;_ `_t Code): City Tel.No. 95 - 5b I, as owner of the property,will do the work and the structure ; ;w„ is not intended or offered for sale(Section 7044, Business 95.50 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, C"4rorJ—; 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 property for �jr�insspection purposes.. SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION CE: 81 (7 A ) APPLICATION FO PLUMBING PERMIT I herebyaffirm that I have certificate of consent to self. CE: e17 z-so insure, or a certificate of Workers'Compensation Insurance,or ' C / a certified copy thereof(Sec. 3800,Lab ) . COUNTY OF LOS ANGE LE BU LDING A SAFETY Policy No. Company E] Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ADDRESS 3 Q Certified copy is filed with the county buij�kq inspection NUMBER FIXTURE OR ITEM • FEE Date&2lye a �ygty LOCALITY 2—v Applicant WATER CLOSET NEAREST BATH TUB CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKE COMPENSATION INSURANCE SHOWER OWNER LAVATORY MAIL (This section need not be completed if the work involved ADDRESS a by the permit is for one hundred dollars ($100) or less.) SINKy�/�� O CITY TEL.NO. ®®_ U I certify that in the performance of the work for which this DISHWASHER permit is issued, I shall not em CONTRACTOR p employ y an y person in any manner 0 so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER ADDRESS / U Date Applicant SWIMMING POOL RECEPTOR W NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO.I�ato Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE / WATELICENSE NO. LIC. Compensation provisions of the Labor Code, you must forth- a/` G ��® • R HEATER CLASS with comply with such provisions or this permit shall be B� DISTRICT NO. P OCESSE� BY deemed revoked. GAS SYSTEM OUTLETS LICENSED CONTRACTORS DECLARATION OUTLETS OVER I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi- FINAL ness and Professions Code, and my license is in full force and DATE �� VALIDATION � � effect. FINALQ b License Numbe Jd"11-Lic.Class `� BY Q PR(Contractor Date �-/ / -17 � !r I am exe pt from the licensing requirements as I am a Plan check fee � acting in my professional capacity (Section 7051, Bus- licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ . �9 ®® iness and Professions Code). TOTAL FEE Lic.or Reg.No. Date Plan check applicant HOME OWNER-BUILDER DECLARATION Name hereby affirm that I am exempt from the Contractor's Address icense Law for the following reascn (Section.7031.5, Busi- Tel.No. ness and Professions Code): 1, as owner of the property, am exclusively contracting 943 S 5 A with licensed contractors to construct the project (Section 7044, Business and Professions Code). # o 0 0 0 0 5 . , . CONSTRUCTION LENDING AGENCY 2.- o 1 250 [ hereby affirm that there is a construction lending agency or the performance of the work for which this permit is o o,.o 2 5 issued(Sec. 3097,Civ.C.). Lender's 0 35 Name 0 0, 1 4 8 2 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 Srdinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the (above-mentioned prop ert f r inspection purposes. 7 Sign re of Permittee Date