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Home My Public Portal About9108 BROADWAY_Plumbing__ -WORKERS:COMPENSATION DECLARATION A PPL P� A TIO Nn FOR PLUMBING p UMBI G PERMIT t 'oa erebth„-offirro Wet I have a certificate of consent to'self in- -pA-0 26 DPW 4/e] Pri IL i"'i WI lL �H� Ytl sure, of a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) _.certified copy thereof (Sec 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLI Policy No.: Company F�- Cert ifled-copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING p ,p Certified copy is filed with the county building inspection ADDRESS 9[m® /0 go/-r 'W department. - NUMBER FIXTURE OR ITEM @ FEE'1 LOCALITY Date Applicant WATER CLOSET(TOILET) s� NEAREST I� �L� �/� CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST, 1j&CS&W6_)i 406 COMPENSATION INSURANCE SHOWER �1 �l /` OWNER (This section need not be completed IF the work involved by Ol V MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY 3 ADDRESS / •T 'r I G I certify that in the performance of the work for which this per- mit is issued, I shall not employ any person in any p'manner so SINK ' CITY TEL.NO, as to become so c to the Workers'Co�—^_i DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ' C) NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS emotion,you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR sation provisions of the Labor Code, you must forthwith comp- CITY J TEL NO. LAWN SPRINKLER SYSTEM ly with,sy��.provisions or this erm t shall by deemed ravak- - - STATE LIC. ed. ,TD`�G��j �_,�J� ,p - WATER HEATER I LICENSE NO. CLASS CdN %("fa s— r LI N$ED TRA ORS'DECL R N DISTRICT NO.. // P ESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS (xij (o/ 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINALGf TALI ATION >_fect. DATE (i ` a License Number I Class _ V FINAL W Contractor Date - BY p �0040A ~ U am exempt under Sec. yL / y_ e , W (U-fIM,.K.t//D~ 3gi1/•q-LKJC.-4AJ a B.BP.C. for this reason Plan check fee 5 5 Z Date: PLUMBING PERMIT ISSUING FEE $ V �1'- - 8250 Signature SINGLE FAMILY TOTAL FEE o -'- 8 2 5 0?-1 _ HOME OWNER-BUILDER DECLARATION Plan check applicant - O,b 2 9'�S 8 I hereby affirm that I am exempt from the Contractor's License Name �.��' CLL (; Law for the following reason (Section 7031.5, Business and Professions Code): Address (08 949AA of A-"1 I, as owner of the property, will do the work and the CitYTFMii G!, Tel. No.3690j-;7,7 structure is not intended ar offered for sale(Section 7044, Business and Professions Code). D CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for r - - the performance of the work for which this permit is 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 D ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the abo e-mentioned p.,royerI for inspection P rpos s. 3 31 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permitlee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby, affirm that I have a certificate of consent to self in- 200026 DPW 4/87 ('V Ir IL Pi YCl sure,or certificate of-Workers'Compensation Insurance,or a 76A667A 9 P CE 817(REV. 8/06) certified copy thereof (Sec. 3800, Lab. C.), Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS ❑- Certified copy is hereby furnished. x FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING a wr ,0. Certified copy is filed with the county building inspection ADDRESS ,/ rJ NUMBER FIXTURE OR ITEM FEE LOCALITY .ir )/ department. @ G ll, l WATER CLOSET(TOILETI Date Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. 0 L(/ COMPENSATION INSURANCE SHOWER OWNER l �/ /nA ( /7U-L'( (This section need not be completed if the work involved by MAIL , the permit is for one hundred dollars ($100) or'less.) LAVATORY ADDRESS I certify that In the performance of the work for which this per- SINK Q CITY TEL N mit is issued, I shall not employ any person in any manner so $(8 'd as to become subject to the Workers Compensation Laws. DISHWASHER 77 I-D CONTRACTOR i+ / Date Applicant CLOTHES WASHER ADDRESS l' NOTICE TO APPLICANT: if, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption, you should become subject to the Workers'Compen- CITY TEL NO. satlan provisions of the Labor Cade, you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shot] be deemed revok- STATE LIC. ed. WATER HEATER !7 LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION V DISTRICT NO. /O�PRO�CEESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS �Q� L�G�`"�-Gd!l� 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER Ped Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL // /, VALIDATION d DATE T /��(/ License Number Lia O Class 0 FINALcc Contractor Date BY 0 II_ ❑ I am exempt under Sec. W CIL 8.&P.C. for this reason D Z Plan check fee - rJwr eJ Date: PLUMBING PERMIT ISSUING FEE S 3 O� Signature , TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name AN k MY9DO �( Low for the following reason (Section 7031.5, Business and , `�"'� 'A"'C"T s re Professions Code): Address a �(/� y ❑ 11 as owner of the property, will do the work and the City GC 1. Tel. N .$/J'�c7 Y'-(5 _ structure is not intended or offered for sale(Section 7044, 1. LTEMS Business and Professions Code). D TOTAL 35 ® 5 CONSTRUCTION LENDING AGENCY (.�iE��'. 35.ctI I hereby affirm That there is a construction lending agency for the performance of the work for which this permit is issued f'}{ANGE „�I-1 (Sec 3097, Ci, C.). Lender's Name ;1[1[111—i ILI(_Ij ` /?7/`"l Lender's Address I certify that I have read this application and state that the above information is correct. I agree 90 comply with all County D ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspec/t/iA n Purposes. JQu{L!A 7�4 ' ' SEE REVERSE FOR EXPLANATORY LANGUAGE �-,;;.2 Signature of Permittee Date WORKERS'COMPENSATION DECLARATION PP IC ION FOR PLUMBING PERMIT I hereby, affirm That I have a certificate of consent to self in- 40-0026 DPW 4/87 APPLICATION IL 'biW OCl II'C 'L7�VE II CI �tl6 sure,or o e of Workers'Compensation Insurance,or certified copyopy t 6A667A thereof (Sec. 3800, Lab. C.) CE 817(REV. 8/86) '- COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy 166-Company ❑ Certified copy is hereby furnished. II FOR APPLICANT TO FILL IN (PRINT OR TYPE) 'ULE NG p �� Certified copy is filed with the county building inspection ADDRESS O department. - NUMBER FIXTURE OR REM @ FEE LOCALITY Date' Applicant WATER CLOSET(TOILET) NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS 7 ,( C� I certify that In the performance of the work for which this per- SINK CITY TET. NO. mil is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. DISHWASHER ' CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption, you should become subject to the Workers'Compen- CITY TEL NO. satlon provisions of the Labor Code, you must forthwith.comp- ly with such provisions or this permit shall be.deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER GG4� fed Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL o VALIDATION a DATE /9-9/ IL License Number L, Class - (� 2i9 FINAL U Q Contractor - Date BY p f am exempt under Sec I W a 0.8P.C. for this reason D Z Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ /3 Signature - TOTALFEE [� SINGLE FAMILY - HOME OWNER-BUILDER DECLARATION Plan check applicant ,t 1 herebyaffirm that l am exempt from the Contractor's License n t P Name _ �' Ei�.Cl .a Law for the following reason (Section 7031.5, Business and � �9 -Professions Code): Address W� ,:rl]7 0,rdi q / ` ❑ I, as owner of the property, will do the work and the City i /'G Tel. No. ' _ �J - i lit s structure is not intended or offered for sale(Section 7044, .�I_ r'i� +p ® s'sf Business and Professions Code). D �- CONSTRUCTION LENDING AGENCY CHECK I hereby affirm that there is a construction lending agency for t 4i ,1111 the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name �I�IUU'LICIC:], 4/ 9f4'L Lender's Address 6.404 2 411?t:lQ I certify that I have read This application and state that the D 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 in ection purposes- / SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date