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Home My Public Portal About9535 BLACKLEY ST_Plumbing__ WORKERS'COMPENSATION DECLARATION AAPPLICATION FOR PLUMBING PERMIT I hereky affirm-that I have a certificate of consent to self 20-0026 DPW 6/87 insure, or a certificate of Workers' Compensation Insurance, 76A667A or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN BUILDING(PRINT OR TYPE) ADDRESS � Certified copy is filed with the county building inspec- � /�i Ci tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET � Q NEAREST TUB r CERTIFICATE OF EXEMPTION FROM WORKERS' ,�, BATH � �U CROSS ST. COMPENSATION INSURANCESHOWER /� D OWNER r (This section need not be completed if the work involved by MAIL. ��1^ C SIless.) A-rf / the permit is for one hundred dollars ($100)or less.) LAVATORY 0 ADDRESS 51 J 3 SIAI-Gk`� I certify that in the performance of the work for which this permit is issued, I sholl'not employ any person in any manner SINK CITY' �- so as to become subject to the Workers'Compensation Laws. DISHWASHERW CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY TEL, NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be ( STATE LIC. deemed revoked. ! WATER HEATER O LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED OESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM —5, OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER ��, and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION 0.1 >; DATE l�/' 7 �� U. License Number Lic. Class FINAL Contractor Date BY ❑ I am exempt under Sec. 0,1.1 B.&P.C. for this reason C/` Plan check fee o Z Z Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name • s. I hereby affirm that I am exempt from the Contractor's License " "I Law for the followingreason Section 7031.5, Business and Address Pr fessions Code): ( u �t y _ Y�I City Tel. No. 11 1, as owner of the property, will do the work and the E #L`(�' structure is not intended or offered for sale (Section ® CA"I'L 14,7 601 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY j I hereby affirm that there is a construction lending agency for '1-ic"'ING the performance of the work for which this permit is issued ` 3 (Sec. 3097, Civ. C.). Lender's Name '-1=)L'i.i- -'i.$ 1 P1 Lender's Address % r k1'a 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 rC Signature of Permittee Date Riv, T OF BUILDING AND SAFETY APPLICATION FOR PERMIT NTY OF LOS ANGELES PLUMBING 1 WILLIAM J. FOX. CHIEF ENGINEER FOR APPLICANT TO FILL IN DISTRICT NO. GROUP ( ZONE PERMIT NO. PLUMBER RECEIVED BY READY FOR DATE ISSUED FIRST INSPECTION ADDRESS BUILDING CITY TEL. NO. ADDRESS COUNTY LOCALITY LICENSE NO. EXPIRES NEAREST PERMIT FEES CROSS ST. NUMBER TYPE OF FIXTURE OR ITEM FEE OWNER MAIL WATER CLOSET (TOILET) @ 0.50 S ADDRESS BATH TUB @ O.50 I CITY TEL. NO. SHOWER (o 0.50 1HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND LAVATORY (WASH BASIN) 2 0.50 AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND KITCHEN SINK @ 0.50 STATE LAWS REGULATING PLUMBING. 1 CERTIFY THAT I POSSESS THE ABOVE VALID LOS LAUNDRY TUB OR TRAY @ 0.50 ANGELES COUNTY LICENSE, OR 1 AM THE LEGAL OWNER OF THE RESIDENTIAL PROPERTY DESCRIBED ABOVE. GAS SYSTEM -�� OUTLETS @ O.50 SIGNATURE OF WATER HEATER @ 0.50 PERMITTEE SLOP SINK @ 0.50 INSPECTION RECORD FLOOR SINK @ 0.50 FLOOR DRAIN @ 0.50 f 7 DISHWASHER @ 0.50 DRINKING FOUNTAIN @ 0.50 1 1- URINAL @ 0.50 HOUSE SEWER @ 0.501 Q MISCELLANEOUS t � O I� APPROVALS DATE INSPECTOR'S NAME ROUGH PLUMBING GAS PIPING GAS VENT CESSPOOL @ 1.00 - CESSPOOL SEPTIC TANK: I SEPTIC TANK DRAIN ( ) PIT ( ) a 1.00I SEWER PERMIT 1.00 GAS TEST UTILITY CO. NOTIFIED I TOTAL FEE $ FINAL f•, - WORKER'S COMPENSATION DECLARATION 20-0026 DPW PW9/89 APPLICATION FOR PLUMBING PERMIT I hereby Vfil�m that I hav$ a certificate of consent to self insure, oc a certificate of Worker's Compensation Insurance, or a certified copy thereof(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) BUILDINGj7,;-3 � Certified copy is filed with the county building inspection ADDRESS < department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. , COMPENSATION INSURANCE ASSESSORMAP BOOK 8 �( b PAGE�S PARCELO (This section need not be completed if the work involved by the SHOWER permit is for one hundred dollars($100)or less.) LAVATORY OWNER L' I certify that in the performance of the work for which this permit AIL JP_O�_ / is issued, I shall not employ any person in any manner so as to SINK ADDRESS 3 '�A� become subject to the Workers' Compensation Laws. DISWASHER CITY T TEL.NO._? Q Date Applicant CLOTHES WASHER CONTRACTOR vo NOTICE TO APPLICANT: If, after making this Certificate of OV�C-�... Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. �- I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER (commencing with Section 7000 of Division 3 of the Business and STATE LIC. ( 9 ) � � LICENSE NO. CLASS U Professions Code,and my license is in full force and effect. GAS SYSTEM U7LETS OUTLETS OVER DISTRICT NO. PROCESSED BY 5 PER SYSTEM D f G� ��,��'�'�" License Number Lic.Class I`_ FINAL 30 �/ DATE VALIDATION III 4_e O Contractor Date (n ❑ I am exempt under Sec. ® FINBY A L1 B.&P.C.for this reason Plan check fee , Signature Date: PLUMBING PERMIT ISSUING FEE$ /3 0 O El Plan FEE �` d Q Plan check applicant SINGLE FAMILY a 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 Code): City Tel. No. I,as owner of the property,will do the work and the structure sv e IN is not intended or offered for sale (Section 7044, Business r I_I i S e 00 and Professions Code). N11111'. t ''a•' _.; _j-I 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, Civ.C.) ;i;-;,=—,rsr;i 3JeOP31_ I_1....L Lender's Name ;y`_3 ! Ar IL 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 epre=f ,on purposes. ty ` r� SEE REVERSE FOR EXPLANATORY LANGUAGE