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Home My Public Portal About5208 BARELA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION a 7( ) APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have certificate of consent to self rM ce 81 617 z-ao insure, or a certificate of Workers'Compensation Insurance,or 1 a certified copy thereof(Sec.3800,Lab.C.) I! COUNTY OF LOS ANGELES BUILDING AND SAFETY E 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 .NUMBER FIXTURE OR ITEM FEE ADDRESS I`I department. LOCALITY / Date p Applicant, WATER CLOSET BATH TUB CROSS ST, Tfl , ' CERTIFICATE OF EXEMPTION FROM WORKERS' ' COMPENSATION INSURANCE > SHOWER s OWNER ego MAI L (This section need not be completed if the work involved / LAVATORY +� _AD D R ESS �_ [) ,L 4 by the permit is for one hundred dollars ($100) or less.) } SINK CITY Tryj' r r'TEL. NO. �csJ• O I certify that in the performaneo��rkers' f the work for which this DISHWASHER permit is issued, I shall not empany person in any manner CONTRACTOR s as to become subject to the Com tion Laws. CLOTHES WASHER O _ ADDRESS Date /�_ ?i�licant � P � -�,1 SWIMMING POOL RECEPTOR TICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO, d Exe ption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM 0 Compensation WATER HEATER LICENSE NO. CLASS TATE p provisions of the Labor Code, you must forth- z with comply with such provisions or this permit shall be DISTRICT NO. PROCESSED 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 $ (commencing with Section 7000) of Division 3 of the Busi- FINAL VALIDATION'r itess and Professions Code, and my license is in full force and DATE ��.��"``�� effect. FINAL License Number Lic.Class BY �t Contractor 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$ acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE " 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 reason (Section.7031.5, Busi- Icitv Tel.No. :�8 2 2 Q R ness and Professions Code): I, as owner of the property, am exclusively contracting 4 o o o o o 5 with licensed contractors to construct the project /� (Section 7044,Business and Professions Code). 2 0 - 2 4,5 0 CONSTRUCTION LENDING AGENCY ° ° ° 2 4, 5 O I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 1 2 0 9—8 2 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 SEE REVERSE FOR EXPLANATORY LANGUAGE ordinance and State laws regulating Plumbing, and hereby authori representatives of this County to enter upon the above entioned p operty for'nspection purposes. Signature of Per ittee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self insure, ora certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR' CONDITIONING, CE-818 or a certified copy thereof (Sec. 3800, Lab. C.) CE 818(REV. 10/81) , Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. F1Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING 5 f' r tion department. (PRINK OR TYPE ONLY) Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST S COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PRCICESSED BY the permit is for one hundred dollars ($100)or less.) AIR HANDLING UNIT,CFM 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 Wogs'Compensation Laws. BOILER, BTU r APPROVALS DATE INSPECTOR'S SIGNATURE COMPRESSOR, BTU 1•moi fy / `J -✓ ROUGH Date Applicant �4�Ce' , '�L� NOTICE TO APPLICANT: If, after makingthis Certificate of VENTILATION SYSTEM FINAL Exemption, you. should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-"UNIT- (commencing USPENDED 'UNIT(commencing with Section 7000) of Division 3 of the Business WALL I and Professions Code,and my license is in full force and effect. A. 0 License Number Lic. Class , 0 Contractor Date El I am exempt under Sec. � t� Plan check fee B.&P.C. for this reason' PERMIT ISSUING FEE $ Sv Date: TOTAL FEE <3 - �_0 Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License , Law for the following reason (Section 7031.5, Business and NAME Professions Code): -32 2 1 A VI, as owner of the property, or my employees with ADDRESS ° o wages as their sole compensation,will do the work and t 0 0 o a CITY TEL. NO. the structure is not intended or offered for sale (Section // 7044, Business and Professions Code). y °.3 g'J El 1, as owner of the property, am exclusively contracting OWNER ,/'-�y +�L�} b�`��! � ° v O U with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS //n /7 (f 12.O 9—8 2 CONSTRUCTION LENDING AGENCY CITY G'� TEL. NO. �'�, /�>��•/ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). 'ADDRESS Lender's Name CITY TEL. NO. Lender's Address STATE LIC. 1 certify that I have read this application and state that the LICENSE NO. CLASS above information is correct. 1 agree to comply with all County ordinances and State laws relating to building construction, andhe by authorize representatives of this County to enter upo` e above-mentioned ploy/rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or- gent Date