The URL can be used to link to this page

Home My Public Portal About9451 BLACKLEY ST_Plumbing__ S'r'O1MPENSATION DECLARATION 75M444 CE 875 (280) MISCELLANEOUS APPLICATION I hereby�a'N�m that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec 3800,Lab C) Policy No CompanyFOR APPLICANT TO FILL IN BU ILDINC ADDRESS' ❑ Certified copy is hereby furnished BUILDING r LOCALIT,1 r ADDRESS J &cx (z_ i ❑ Certified copy is tiled with the county building,inspection NEAREST,, department LOCALITY' Tj� �j CROSS ST Date Applicant NEAREST 1 L Ci DISTRIC` NO G UP T PE / PRO D BY CROSS ST QV�� Q, ,.[ _;� ONSTV CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL„ , v t J ,DESCRIPTION LOT NO BLOCK ^' MAP HIGHWAY >-- COMPENSATION INSURANCE' No (CIRCLE) STATE MAJOR SECO LOCAL s - _ NO OF BLDGS O (This section need not be completed If the work involved TRACT r y NOW ON LOT , US ZONE�SPECIAL,CONDITIONS by the permit is for one,hundred dollars ($100) or less) USE OF U SIZE OF LOT 1 X EXISTING BLDG ' I cc 'I certify,that In the performance of the work for which this 0 permit is issued, I shall not employ any person in any manner OWNER1 Q' 4 F- so as to become subject to the Workers' Compensation Laws MAIL Q y� 1 OCCUPANCY GROUP ti a ADDRESS r) Date Applicant rEL z NOTICE TO APPLICANT If, after making this Certificate of ."Y Q a' No 1Qj�a�" 3Z OCCUPANT LOAD Exemption, .you should become subject to the WorkersAPPLI ATIONFOR EXIT HARDWARE.' i Compensation provisions.of the Labor Code, you must forth- ° With comply with SLLCh provisions Oi this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ ❑ No Spec Knowl ❑ , deemed revoked _ ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) NO OF EXITS 6 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and PARKING. effect SPAC'ES ' REO'D O PROVIDED O License Number Lie Class LIMITED TIME USE Contractor Date DATE DATE ❑ FROM To licensing 1 y ' I am exempt from the linsing requirements as I am a t licensed architect of a registered professional engineer, SIZE OF No OF INSPEcroR's acting in my professional capacity (Section 7051, Bus- EXISTING`BLDG STORIES SI NATURE FINAL,APPROVAL BUILDING , Lie or Reg No Date &ae' mess and Professions Code) _ PRESENT USE OF / tw ' HOME OWNER-BUILDER DECLARATION ON LO O EXISTING BUILDINGS OT AND USE ` . 1 ' I hereby affirm that I am exempt from the Contractor's < License Law for the following reason (Section 7031 5, Busi- w @,4'5 S 5`A ness and Professions Code) NO PARKINGSPACES,PROVIDED - ❑ I, as owner of the property, will do the work and the 3 0 structure Is not intended or offered for sale (Section MT 7044, Busmess and Professions Code) - -e o 8 Q 5 0 ,y n „ � PROPOSED USE OF BUILDING , � b - CONSTRUCTION LENDING AGENCY 1i a *,,9,8 Q 5 0 5 I hereby affirm that there is a construction lending agency ` 'for the performance of the work for which this permit is 0 S 0,5_8 6 Issued (Sec 3097,Civ C) i Lender's Name — PROPOSED.MAX OCC Lender's Address PERMIT FEE 4a U I certify that I have read this application and state that the above information is correct I agree to comply with all County ISSUANCE'FEE ordinances a d State laws relating t ding constructwn, and h uthor represe ive of t is County to enter TOTAL FEE rro upo the ove- coned o ert fo n'spection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Si a of Permittee Dates " 76A667C (CE-6178( -9/75 ��! / l.� �' �!-7/ APPLICATION FOR PLUMBING PERMIT {J BUILDING AND SAFETY DIVISION FOR APPLICANT TO FILL IN IPRINT OR TYPE) BUILDING ` NUMBER FIXTURE OR ITEM @ FEE ADDRESS 5 CSI WATER CLOSET LOCALIT Lp 1 C NEAREST BATH TUB CROSS ST SHOWER OWNER T� AIL M LAVATORY ADDRESS �_CS ( �� SINK CITY In' C1 TEL I DISHWASHER CONTRACTOR CLOTHES WASHER ADDRESS SWIMMING POOL RECEPTOR _ 'q / 13 CITY �� -TEL NO 35I 0 l%/ LAWN SPRINKLER SYSTEM STATEC LIC WATER HEATER LICENSE NO `� � C LASSC ` a 1 GAS SYSTEM OUTLETS DISTRRR�T NOGRO P OCE ED Y V OUTLETS OVER ` U p�iO 5 PER SYSTEM INDUSTRIAL V WASTE APPROVAL Ly d INSPECTION RECORD Z 7-657 C Plan check fee • S/� �"' /j-%o✓6 PLUMBING PERMIT ISSUING FEE $ \4 so TOTAL FEE Plan check applicant Name APPROVALS DATE INSPECTOR 5 SIGNATURE UNDER SLAB WORK Address ROUGH PLUMBING City Tel NO GAS PIPING 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION GAS VENT AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER PLUMBING I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES LICENSED AS REQUIRED BY LO (G COUNTY AND STATE OF GAS TEST -72,A, CALIFORNIA OR THAT I AM T LE AL O ER OF, AND INTEND TO RESIDE IN THE ABOVE DESC I ED RE I ENT AL PROPERTY UTILITY CO NOTIFIED SIGNATU RE r OF PERMITTEE U FINAL ~-.PLAN CHECK VALIDATION cK M 0 CASH PERMIT VALIDATION cK Q CASH T3 142 VIN 30 b M ;.5 0 ♦P,6 G Y r 7 � WORKERS' COMPENSATION Q,E�yTION l„ 20-0026 DPW_4/87 APPLICATION FOR PLUMBING PERMIT I hereby affirm that I•fjave�a cetiif(s8te o�consent o self in- 76A667A sure,or a,certificate of Workers'Compensation'fnsurance,or a CE 817(REV 8/86) F certified co y thereof (Sec 3800, L Policy IN �S Company �!%/l COUNTY OF LOS ANGELES �/J`�5/ 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 ADDRESSf d pc?rtment _ ° a a NUMBER FIXTURE,OR ITEM Ca FEE _ $ O O LOCALITY 3 Dat e<" 1� ` Applicant/ WATER CLOSET(TOILET) pp NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB / 06 CROSS ST GOMPENSATION'INSURANCE / SHOWER, d' OWNER, l/^/ /l�d`�( veSs� , (Thi's section need not be completed if the work involved by 7 MAIL C� the permit is for,one hundred dollars ($100)or less ) LAVATORY- s - a U' ADDRESS ✓ry I certify that in the performance of the work for which this per- G ' mit is issued, I shall not employ any person in'any manner so SINK . GgUNO�Y� 0 CITY A TE (� �l/_ �7 as fo`become subject to the Workers' Compensation Lows o'V DISHWASHER CONTRACTOAle 114112leolv6", a - Date Applicant "' CLOTHES WASHER !� NOTICE TO'APPL'ICANT If, after making this Certificate of Ez- , ' ADDRES ,D Z,!J L(/_ 4S.4 ; SWIMMING POOL emption, you should kiecome subject to the Workers'Compen- RECEPTOR, CIT}��-/' T y✓ sdtion provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ly,with such provisions or this permit shall lce deemed revok- STATE �j Q�j CI LIC edt WATER HEATER LICENSE NOzx /7d ' / CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCES BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS, SO 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER fec Professions Code,-and my license is in full force and of 5 PER SYSTEM FINAL )CP ALID TION l� 00 CL O License Number/',! �T Lic Class U 1 9 ddp� '31 r a O ' Conlractot� �C.�dN� Dat � / f r F 'I am exempt under Sec _ t W B 8P C for this reason y. N Plan check fee f Date -' PLUMBING PERMIT ISSUING FEE$ d D ' Signature - --- TOTAL FEE pU SINGLE FAMILY. -E HOME OWNER-BUILDER DECLARATION, Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name r Law-for the following reason (Section 7031 5, Business and _ r W C Professions Code) Address N z� rev ot� Tel No _ - 3�r I, as owner of the property, will*do the work and th`e City 6 s - structure is not intended or offered for sale(Section 7044, a f IT and Professions Code);- JOTAL �1 JUS 00 z Aw' CONSTRUCTION LENDING AGENCY; - r f Lf„ECK 1jc■j €� 1 hereby affirm that there is a construction lending agency for the performance of the work for which this' permit is issued .d _ t`H {[1 ■�f?€ (Sec 3097;Civ*C ) -Lender's Names,� ~r23 "Cl t .. ' Lender's Address - 9102 1 AM 9 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 regul8`ting Plumbing, and hereby - a horize representatives of this County to enter upon,the a ov -menti roperty for inspection purposes r SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date '