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Home My Public Portal About9325 BROADWAY_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION PPLIC A 1i ION FOR PLUMBING DA B ApplDollB,rT PERMIT I hereby affirm that I have a certificate of consent to self 76A667A YYIr Ir 'b P9 Y UCI Ir II'� Ir IL YJ'9Htllm II CI`�9 Ir IG B'(FN9 II insure, or a certificate of Workers' Compensation Insurance, CE 817(REV.10/BI) —T or a cerlified copy thereof (Sec 3800, Lob. C.) COUNTY.OF LOS ANGELEST,r BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished.. f_1 Certified APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec- ADDRESS Os tion deportment. NUMBER FIXTURE OR ITEM @ 'FEE �� Dale AppliSam WATER CLOSET NEAREST LOCALITY 7a AIL a Its CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CRO55 COMPENSATION INSURANCE SHOWER OWNER ! ^Q (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS �Q I certify that in the performance of the work for which this ^M PA permit is issued, 1 shall not employ any person in any manner SINK CITY TEL. NO. so as to become subject to the Workers'Compensa ion ws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY ez TEL. NO. Compensation provisions of the Labor Code, you must forth LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCESSEQ�BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS /) (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER v a and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL _ VALIDATION V License Number Lit. Class- DATE lass J ^ FINA O Contractor Date BY V ❑ W I am exempt under Sec. d N B.BP.C. for this reason Plan check fee Z Date: PLUMBING PERMIT ISSUING FEE$ O SO D Signature TOTAL FEE O SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION Name .:910 O 9 .� a I hereby affirm that I am exempt from the Contractor's License gddress e 5 Law for the following reason (Section 7031.5, Business and H o o Professions Code): City Tel. No. ' 'o 0 ❑ I, as owner of the property, will do the work and the 2:0,0 6 50 structure is not intended or offered for sale (Section D ,o { •Z;C 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CIE 02-84 2 g4 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Gv. C.). Lender's Name Lender's Address 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 - obov -mentioned property for inspection purposes, d l 340-94 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date T 5 WORKERS'COMPENSATION DECLARATIOR! APPLICATION-FOR PLUMBING IIJ'YtlBI�011G'>t9 Ir IL IPLItlB�� I hereby affirm that'I have a tenificore of consent to self 76A667A Insure, ar o certificate of Workers' Compensation Insurance, CE 017(REV. 10/81) or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company - Certified copy is hereby furnished. BUILDING ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS Certified copy 1s flied with the county building inspec- tion department. NUMBER FIXTURE OR ITEM @ FEE I� /y f /f / LOCALITY Date - Applicant WATER CLOSET (� d>m /,NEAREST (/ CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CROSS ST. ��.G1(�� / COMPENSATION INSURANCE SHOWER ! Op OWNER q e� M ,1 . . (This section need not be completed If the work involved by (L MAIL the permit is for one hundred dollars($100)or less.) LAVATORY mB ADDRESS d tC U/7•(J Kl/1 I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY C/iEL. NO. so as to become subject to the Worker Compensation Laws. DISHWASHER /1 �s CONTRACTOR F-L Dole `� '� � Applico CLOTHES WASHER ADDRESS ^w NOTICE TO APPLICANT: If, after making th' Certificate of �� UlL1 J/� / Exemption, you should become subject the Worker SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth CITY Sjfl1 TEL NO LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE 0'' ll LtC. c�_3 deemed revoked. WATER HEATER G pp LICENSE NQ V CLASS LICENSED CONTRACTORS DECLARATION D15;AICT NO. PROCESSED BY BO (hereby affirm that GAS SYSTEM OUTLETS am licensed under provisions of Chapter 9 �JGA /�— 1 ( commencing with Section 7000) of Division 3 of the Business OUTLETS OVER /'� and Professions Code`,and my license is in full forces and effect. 5 PER SYSTEM FINAL VALIDATION V License Number / Oan� ?W Lic Class -36 v G !�v L .0 DATE � l—Sa t .71117S L/'S R FINAL r 0 Contractor FT�" m PLOVEY Dote Irk-jIbJ BY �! I am exempt under Sec. B.BP.C. for this reason �^ i G Z Dal : Plan check fee PLUMBING PERMIT ISSUING FEE$ Q B 9 Signature ' TOTAL FEE /� Plun check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Nome 'f o 0.0 o o s 1 hereby affirm that I am exempt from the Contractor's License ' Low for the following reason (Section 7031.5, Business and Address _ 2'0 ' 52 , a Q Professions Code): City Tel. No. F1one 25CT I, as owner of the property, will do the work and the c- structure is not intended or offered for sale (Section D 12 1 7044,t Business and Professions Code). 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.), 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 ordinances and State laws regulating Plumbing, and hereby Ajauutt/thhorize representatives of this County to enter upon the _5 " e-mentioned roperty for inspection purposes. Id-116 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature P rmittee Date