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Home My Public Portal About9331 BROADWAY_Plumbing__ - .�WORKERS' COMPENSATI- DECLARATION, � APPLICATION FOR PLUMBING PERMIT I hi eby��9m that I have a cernficate'ohdonsern'to self in p"�26 DPW a/e] sure, ora cert'ficatEo�Vbikers'Com ensolion Insurance,or 76A667A ' P CE 817(REV:.8/86) - M certified copy Thereof{Sec. 3800 Lab C:) - . . COUNTY OF LOS ANGELES' DEPT. OF PUBLIC WORKS - .Policy No Company, _ a - . - IiCertified copy is hereby furnished.• FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING, Certified copy isfiled with the county bu,Iding inspection. ADDRESS YY department. - „ NUMBER FIXTURE OR ITEM - • _ r LOCALITY v - - "WATER.CLOSET(TOILET) Date•. Applicant - NEAREST CERTIFICATE OF EXEMPTION`FROM WORKERS' '� BATHTUB �/ a CROSS'ST. �efl /1150 s. y COMPENSATION INSURANCE ' SHOWER - OWNER (This section need riot be completed if the work"involved by MAIL 1- _ G., .„ ' the permit-is for one hundred dollars ($100) or leis:) LAVATORY - ' ADDRESS ^ I certify that in the performance of the work for which this per- - - - mit is Issued, I shall.not employ any person'in any manner so SINK CITY s �,�TEL NO�L� ` X973 as to become subject to the Workers' Compensation Laws. DISHWASHER - '- !�l A - CONTRACTOR sLCL ppicaG�'�'+«' CLOTHES WASHER A NOTICE TO APPLICANT: If;after making this Certificate of.Ex- emption,you should become subject to the Workers Compen- SWIMMING POOL RECEPTOR CITY TEL..NO. ly with such i roI of the Labor Code,you permit shall must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or This permit shall be deemed revok- STATE tic, ed. -, .t. - - / WATER HEATER LICENSE NO. CLASS . LICENSED CONTRACTORS DECLARATION DISTRICT NO. PRO ED V.. I hereby affirm that I am licensed under provisions of Chapter GAS.SYSTEM OUTLETS A 1) �-1 9(commencing viith Section 7000)of Division 3 of the Business .OUTLETS OVER and Professions Code, and my.l icenseis in full force and ef- 5 PER SYSTEM FINAL VALIDATION y Lice. - _ DATE s —/ O License Number Lic. Class. - O FINAL S Contractor Date - - - BY C OI am exempt under Sec. _ _ _ _ W a B &P.C. for this reason Plan check-fee D ! - H Z 'Date: PLUMBING PERMIT ISSUING FEE$ Signature - ' - TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant _S� r I hereby affirm that I am exempt from the Contractors License Name I•^ is Low for,the following reason (Section 7031.5; Business and _ _ ,� 8 1 1, U Professions Code): Address y �I,- as owner of the property, will da.the work and the City - Tel. No. - structure isnot intended or offered for sole'(Section 7044, 'f _ Business and Professions Code). .T. D - CONSTRUCTION LENDING AGENCY - 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.). ' t ' Lender's Name Lender's Address i' '•s ' I certify that I hove read this opplicotion;ond.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-menticned•prop ty for spa n purposes. r SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of P rm itte • rt. py p� I� Ip PLUMBING 111ppI� py 1 -j WORKER��S'COMP ENSATION'DECLARAfION APPLICATION OOR PLUMBING -PERMIT . -Ihereby a(firm'Ir_ I have o.certificate of consent to self in- 76A,56 A 4/87 n sure,ora certificate-of Workers'Compensation Insurance,or o 76A667A dull P CE 817(REV 8/86) - certified copy thereof (Sec. 3800, Lab. C.) I "• ' COUNTY OF LOS ANGELES _ DEPT. OF PUBLIC WORKS P bcy No Company - t . i. . . _ j• �- Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILE IN(PRINT OR TYPE) .Certified copy is filed with the county building inspection - ADDRESS �J? ? depcirtment. r. NUMBER` - FIXTURE OR ITEM @' FEE - - .. o .. - _ LOCALITY Dote_ �.�J� Applic- < Imo` Y 'w �� • WATER CLOSET(TOILET) NEAREST. - - - . !vim' . CERTIFICATE OF EXEMPTION PROM BATH TUB WORKERS' � � ,I, - �� CROSS ST.. _ ' COMPENSATION INSURANCE., OWNER (This section need not be completed if the work involved SHOWER by MAIL the permit..is for one hundred rdollars (9100)'or less.)- LAVATORY �Q -ADDRESS I certify,thot in the performance of thework foi'which this per- SINK - mit is issued, I sholl'not employ any person in any manner so CITY TEL.-NO,fj? _ ,�j Date become subject to the Workers'Compensation Lows. DISHWASHER '- _ ✓C% as,to �y/ CONTRACTOR ��dii� �GQGI 3 'I ApplCLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Eenificate of Ex- 'SWIMMING POOL RECEPTOR f emplion, you should become subject to the Workers'Compen-: CITY TEL. NO. sation provisions of the labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM ly with such provisions or this permit shall be deemed Tevak- .STATE LIC. t ed. _ - / WATER HEATER LICENSE NO. CLASS ' LICENSED CONTRACTORS:DECLARATION DISTR$Q_NO.�) PR ED BY ' 1 hereby affirm that I am licensed underprovisions of Chapter GAS SYSTEM OUTLETS V 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER L - and Professions Code, and my license is in full force and ef- 5 PER SYSTEMfectf FINAL VALID TION a .^ t- DATE ,� C License Number Lic. Class U .. �^ FINAL S Contractor Date ' - BY c O P_ _ y F] I am exempt under Sec. - ANI .a _. W . . a &P:C this reason Plan check fee D- _ 33,37 amu._tlT Z ` Date:- RUMBLING PERMIT ISSUING FEE $1TT 10 Signature, ,1 "EI.0 TOTAL FEE Q8 a 5O SINGLE FAMILY TOTAL +-++= HOME OWNER-BUILDER DECLARATION Plan check-a'ppliconi �'� c I CHECK ..0 hereby affirm that I am exempt from the Contractor's License Name` - - - CHANGE' .(l0 Law for the following reason (Section 7031 L5, Business and Professions Code): Address - - I, as own er of theproperty, 'will do the work and the City 'Tel. No., f L;�' r D�=j' strut Nre is not intended or offered for sale(Section 7044, , Business.and Professions,Code).' 0016, Ana 5:5 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 f I certify that I have read this application and state that the - - -above information is correct. Iagree to comply with all County - D ordinances and State lows regulating Plumbing'and hereby - a _ authorize representatives of this County to enter upon the „• - obove-mentioned prop ty for peceo uiposes. SEE REVERSE FOR EXPLANATORY LANGUAGE• - Signature of Permi tee Date �, - ' _ L` WORKER'S COMPENSATION DECLARATION DPW 9/99 APPLICATION FOR PLUMBING PERMIT Ll ] I hereby affilrn'th� I haveea a certificate licate eF consent to self insure, 7B 002 A667A or a certificate.of Worker's Compensation Insurance, or a certified copy thereof Sec.3800 Lab. C.) I I - ./ 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) BUILDING ❑ Certified copy is filed with the county building inspection ADDRESS department. I NUMBER FIXTURE OR ITEM ® FEE LOCALITY Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. «JS COMPENSATION INSURANCE I ASSESSOR (This section need not be completed if the work Involved by the SHOWER MAP BOOK PAGE PARCEL permit Is for one hundred dollars($100)or less.) OWNERf /�' �f I certify that in the performance of the work for which this permit LAVATORY is issued, I shall not employ any person in any manner so as to / SINK ADDRESS MAIL.� .E.I32m *�iQ' become subject to the Workers' Compensation Laws. O DISWASHER CITY �� ] TEL. Date Applicant CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR _r 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 fl (commencing with Section 7000)of Division 3 of the Business and STATE LIC. 0 Professions Code,and my license is in,full force and effect. GAS SYSTEM OUTLETS LICENSE NO. CLASS (� OUTLETS OVER DISTRICT NO. PROCESSED BY Q 5 PER SYSTEM0 License Number Lic.Class .fox 6 h- U iti /vf r, FINAL DATE �_� / VALI_ DAT_IQ�N LU J Contractor Date - 1) ❑ i + I am exempt antler Seo. FINAL '3'-'ll7 _Z / By �� M r_, B.&P.C.for this reason Plan check fee _ Date: D TOTAL f-�' e 7 5 Signature PLUMBING PERMIT ISSUING FEE S 117�1 TOTAL FEE �� / CHANGE ❑ l_I SINGLE FAMILY Plan check applicant 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 � B� Code): ,- ''-'14 1 AN i(I� ii City Tel. I, as owner o/the property,will tlo the work and the structure is not intended or offered,for sale (Section 7044, Business and Professions Code). D 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 D 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 prop y for inspection purp es. _ s� � SEE REVERSE FOR EXPLANATORY LANGUAGE Signature oU Per itt—rr�ee Date