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HomeMy Public PortalAbout4818 BIRCHLAND PL_Plumbing__ WORKI RS'COMPENSATION DECLARAnON APPLICATION FOR PLUMBING PERMIT I hereby affirm that'1 have a certlficatp of consent to self. 7616e7A - a insure, or a certificate of Workers'CoMpensatlon Insurance, CE 817(REV. 10/6]) or a terttfied copy thereof{Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy NoPa � O Company Z dP�.--/ Pol Certified copy I's hereby fumishpd. FOR APPLICANT Tp SILL IN(PRINT OR TYPE) BUILDING ��. I Certified copy Is filed with the county building IRspec- � tion department. NUMBER F1X7URE Ol?pT�A O FEE Lin WATER CLOSET ` bate4F­ Applicant44s�!=_ NEAREST CERTIFICATE OF E?O=YPTION PROM WORKERS'. STN 74B CRO55 ST. A-&a>e Y` COMPENSATION INSURANCE SHOWEROWNER (This sec"on Deed not be complatad N t4 work Invahred by therm ptM it for one hundred do Ilarw ($100)or lets.} LAVATQRY AppRE$S f r I certify that in the performante of the work for which this permit Is Issued, I aball not employ any Person In ahy manner SINK CITY I 1H.NO ff to as to became subject to the Workers Compensation Laws. piSrfWAS R mNTRAcroR r 4 a Date A—litgnt CtOT14ES WAS4-ER o ADDWMS RO NOTIC5 TO APPLICANT: If, after making this.Certtficatp of Exemption, you should become subject to the Wockers' SWIMhAItiG POOi RECEPTOR Compensation provisions of tfie Labor Code, you most forth- CInC 4 LAWN SPR INI�ER SYSTEM with,comply with such provlflohs or this permit shall beA / — UC. deemed Fevbked. WATER HEATER UCR4SE NO. 7 GLASS �— llaNSEI)CONTRACTORS DECLARATION DISTRICTBY I hereby affirm that i am licensed under provl*iona of Chaptor9 fAS SYSTEM OUTLETS (commenting with Section 7000) of blvislon 3 of the Buslness OUTLETS OV9t I dnd Professions Cod.9 and my iiceraio Is In full forte and effect. 5 PER SYSTEM FINAL p 0. DATE Q r� VALIDATION u License Number / 6-7 6, Ito I Ic. Clots��- Z-° oc ` FINAL G Contractor�,���o�s lane n,to-.�`� 7' BY T W I am exerrapt under Sec. IL B.B P.Q. for this reca6 h Y Plan check fee pate: PLUMBING PERMIT ISSUING Pq$ Slghatun+ TOTAL FEE Plan cheek applicant SINGLE FAMILY ROW OWNER-BUILDER DECLARATION Name f 4 2f.S,1 A 1 hereby off Irm that I am ox4mpt from the Cvrltractbri Hearse Law fpr the following reason (Section 7031.5, Business and Mets # a o o o n 5 Prroofesslons Code): City Tel.No. LJ 1, as pwnar of the property, wlfl do the work and the 2 °,° 1 6.50 structure Is not Intend-6d or offered for sale {Sattiort 06 7044, Business and Profeuions Code). ;o.o ° Jp CONSTRUCTION LENDING AGENCY R04- 8 3 I hereby affirm that there Iso eonstrvctlon lending agency for the perforh5ancq of the work for which this p6malt Is Issued .).Le($ec. 3097, Clv_C.).- Lender's nder's Nam& Lender's P�¢dress I certify that I have rood this application and state that the , Above Infornrxwtlon Is correct. I agree to comply with all County ordinances and State laws royulating Plumbing, and,hereby authorize representatives of this County to enter upon the above-mentldned property for fhspectlon purpotba. TEE REVERSE FOR E)CPLANATaRY LANGUAGE 3 I9nature P ttee Date woRta=Rs'cDMPENsAn4w DEqafta,Tloel� .2Q-0026 DPW 1-herdby, affirm that I have a cerflflcote of consent to self In- 4/87 APPLICATfON FOR PLUMBING PERMIT sure;or a cprtlfL ate of Work ep Cooipeltwtlon Insurance,or a C (may.'") certified copy thereof (Sec. 3$00, Lab.`C ). COUNTY OF LOS ANGELES -DEPT. OF PUBLIC WORKS Policy:Nd.' Coihpohy .Certffled copy is hereby furnished:, FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING p p� C`ertt'fled copy is filed with the county bulfding tnapectron NUMBER FIXTURE f�E ADDRESS q(7 j p ( A - depar"ent. _ Lim WATER CLOSET(tPILFr) Date Applicant NEAREST CERTIFICATE QF EXEMPTION FROM WORICERS' BATH TUB CROSS ST. COMPENSA'rION INSURANCE ' Si O'WINER E fmis sect;&VrTm rko4-be'cpmplet+dr M t wo k_IepFv�d vby the permit U for ofie hundred dollars ($ 00)or Jess.) LAV470RY l! ,MAI� -S � I,.c6rtlfy that•In the perforr tdnce of the work for which this per: mit Is issues, I shall riot employ any p6rson In ari t manner to SINK CTY T TEf NO.3SV_ as to become fUlSJect 10 the Workers'borrtpensatlor)Laws. DISHWASHER TOR y ^' QOt bate AppllcantCLOTI ES WASITER NOTICE TO APPLICANT:1f, affer making this C`et4lcpte of Ex- SWIMMING POOL RECEPTOR ADDRESS r -emotion,you should become subrect to the kVdd"'Compen- CIT Ta; tip satlon provlslonaof the'Labbr Code,you trwst for'tl;wlth-comp- LAWN SPMNK'> SYSTEM ' Jy with such prpvitions or this permit shall be deemed revok- STATE LF__ ed. .. WATER 1-I EATER LICENSE NO. CLASS rLiCENSED C©NTRACTOR$DECLARATION DISTRICT BY I hereby affirm thdt I am Ilcerued under provlslons of Chapter GAS SYSTEM OUTLETS 91(commencing with Section 7000)of Dlvlalgn'3 of+6 Quslness OUTLETS OVER Oro and Professions(~ode; Qnd my license Is in full force and ef- 5 PER SYSTEM FINALALIDATION n fect. DA]-ETW a License Number Llc.,Clcm V - - - FINAL Contractor Dpte BY O H ❑ 1 am exempt under Sec." W {• B.BP.C, for this reason Plan check fee, Dqte: PLUMBINGpE_RMIT ISSUING FEE; , Slgnoturo TOTAL FSE t • -5INGL�FAMILY - 4--1OME0W1NER-BUILbER DKLARAT[bN) Plan check appllcan.t I hereby affirm that I am exe'rupt from the Contractors License Nome. - Ah Law for the fo116WIng-reason (Section 7031,5, Buslnen cod ACCT■yJL Professlons Code): Address �• 50 1, as owner of the pr°�erty,.wlll•do the.work and the City... Tel.No. structure Ts not Into'des or offered for sale(Section 7044r 1 ITM Buslness and Profeulon;Code). TOTAL 46M50 - CONSTRUCTION 6M50 - CONSTRUCTION LENDING,AGENCY 50 t hereby affirm that there Is a cpnstruc►lon lending agency for ■ tfie performance of the work for Which'thls Rermlt Is issued .00 (Sec. 309/7, C1v. C,). c^. Lender's I.Qme -U G S - 0000—OMI .12/20/89 //,,�..,,o,,�? 1J tendpr.'a Address J•��"/ � ■36 v� A��. 76ti�7 � Af111 I {601fy that I have read this application and state that them above Inforatlon Is correct. I agreerto comply with all County ` ordlnances dndState laws rsbulating Plumbing, and hereby authorize representatives of this County to enter upon the , ve-mentlo ed perty.for Insped Ian.purposes• SEE REVERSE FOR EXPLANATORY LANGUAGE Ignature of Permittee .b, Date