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Home My Public Portal About9400 BROADWAY_Plumbing__ WOthat 1 have a certificate of 76A66Z DPW 9189 APPLICATION FOR PLUMBING PERMIT lJ 0-0026 I hereby affirm that Lhave a certificate of consent to sell-insure; or a-certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab.C.) - Policy No. Company COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. _ ❑ 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. NUMBER FIXTURE OR ITEM @ FEE !D LOCALITY Date Applicant WATER CLOSET NEAREST ' CERTIFICATE OF EXEMPTION FROM WORKERS' - BATH TUB CROSS ST. / COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER - MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) OWNER n i. I certify that in the performance of the work for which this permit LAVATORY is issued, I shall not employ any person,in any manner so as to SINK MAIL become subject to the Workers' Compensation Laws. ADDRESS 7/ q0 DISWASHER /� CITY TEL.NO. Dto a �L.Sj_r_�Applicant -�'• CLOTHES WASHER U CONTRACTOR. �Vl•r' NOTICE T O APPLICANT: If, after making this Certi kale of Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY E . I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER d (commencing with Section 7000) of Division 3 of the GAS SYSTEM OUTLETS LICENSE NO. CLASS Business and STATE LIC. O („) Professions Code,and my license is in full force and effect. - ISTRIC N ESSE BY 1 OUTLETS OVER - Q 5 PER SYSTEM O License Number Lic.Class U FINALVA DATION w DATE d Contractor Date _ (q El am exempt under Sec. 9V A` TW t Z B.BP.C.for this reason Date: T Plan check fee D Signature PLUMBING PERMIT ISSUING FEE$ OV ❑ TOTAL FEE g Fqj c (' SINGLE FAMILY Plan check applicant ACCT.t HOME OWNER-BUILDER DECLARATION Name V 7 I hereby affirm that I am exempt from the Contractor's License Law '_ 0 ,I I for the following reason (Section 7031.5, Business and Professions Address Code): 1 ITEM: ❑ �it-f�3 I,as owner of the properly,will do the work and the structure City Tel. No. TOTAL ?v e 00 is not intended or offered for sale (Section 7044, Business ^`` and Professions Code). D (-,.HECK t 46'.CI:I CONSTRUCTION LENDING AGENCY CHANGE .131-1 1 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.) 0000-00111 7i 619it Lender's Name 1690 1 AM 7:12 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 Stale 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 WORKERS' COMPENSATION DECLARATION. I hereby, affirm that I have a cercertificate'of consent Jo self in- 20-0026 DPW 4/137 APPLICATION FOR PLUMBING PERMIT sure,or a certificate of Workers' 76A667A Compensation or a P CE 817(REV. 8/86) _ certified copy thereof (Sec. 3800 Lab C Policy No. Company - COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS ' " � - ,. _ .Certified copy is hereby furnished. _ - • TYPE( FOR APPLICANT TO FILL IN(PRINT OR -BUILDING Certified copy is filed with the county building inspection ADDRESS .. F ' departmFI ent. .,f. NUMBER . %TURE'OR ITEM @ FEE LOCALITY• _ s Date Apphccmt WATER CLOSET(TOILET) NEAREST CROSS,5T. ,CERTIFICATE,OF EXEMPTION FROM.WORKERS' BATHTUB .COMPENSATION INSURANCE • - OWNER (This section need not ba completed if the`woik involved by SHOWER- MAIL the permit is for one hundred dollars (5100)or less.) LAVATORYADDRESS9ZL11,17?A70A7) WAY I certify that in the performance of the work for CvHich this per- mit er- - Q mitis issued, I shall not employSINK any person in any manner so - .CITY TEL NOe'-Q as to becom subje tot a Workers C mpensation Laws. DISHWASHER Oy /{O�("'/}� � q� CONTRACTOR Date /O `c`+Appl cant �L�+'� � CLOTHES WASHER ADDRESS NOTICE T APPLI ANT If, after making this Certific a of Ex- n Q /� emption,-you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR sotion provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM - CITY T TEL'NO ly with'such provisions or this permit shall be deemedrevok- STATE - - LIC. ed. - . ' WATER HEATER LICENSE NO. - CLASS LICENSED CONTRACTORS DECLARATION - DISTRICT NO. . PROCESSED BY •I hereby affirm that I am licensed under provisions ofChapter GAS SYSTEM - OUTLETS 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 - DAN EL VA ATION a fect. License Number Li<. Class O FINAL U Contractor Date BY S s.', 0 U I am exempt under Sec. �' W a B.BP:C. for this reason D ' !l' Plan check fee (A Z Date: _ PLUMBING PERMIT ISSUING FEE$ Signature' - TOTAL FEE # SINGLE FAMILY - HOME OWNER-BUILDER DECLARATION ;Plan check applicant - ( ° e QQ • I hereby affirm that Pam exempt from the Contractor's Buiness and Name - � - � ° ° ° ��Sj 0 Law for the following reason (Section 7031.5, Business and '• • I �, Q tSS Professions Code): Address - 1;'as owner of the property, will do the work and the City Tel. No. structure is not intended or offered for sale(Section 7044, Business and Professions Code). " I 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 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 upo the abo mentioned pro erty for inspection purpa s. ' / ytOs- m 28 e SEE REVERSE FOR EXPLANATORY LANGUAGE Y Signature of Permits a Date - 4�` — $ORKERS- COMPENSATION DECLARATION APPLICATION FOR PLUMBING ® RM IT ..d herebyof#irm that I have a certificate of consent to self' 76g667q - _. .. __. ... . . .. _.,. .. .._. insure, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) or a certified copy (hereof (Sec:3800, Lab. C.) - COUNTY OF LOS ANGELES — -BUILDING AND SAFETY 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 inspec- ADDRESS lion department. NUMBER FIXTURE OR ITEM @• FEE LOCALITY WATER CLOSET Date Appli4ont NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSSST, -- - f COMPENSATION INSURANCESHOWER OWNER ' 1 v r This section need not be completed if the work Involved by- OWNS . the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS I certify that in the performance of the'work for which this permit is issued, ['shall not employ any person in any manner 'SINK -�L� �F - CITY; - IWV TEL. NO. so as to become subject to the Worker 'Compensation Laws. DISHWASHER - - _ CONTRACTOR Dat 0— .0 r - CLOTHES WASHER ADDRESS._ .- NOTIC O APPLICANT: If, after oking this Certificate o Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY. TELNO. . LAWN SPRINKLER SYSTEM with comply with such.provisions or this permit shall be STATE U LIC. deemed revoked. - WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. P OCESSED BY I hereby off irm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS U (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license Is In full force and effect. 5 PER SYSTEM FINAL VALIDATION License Number Lic. Class DATE FINAL U. Contractor Date FI 0 ❑ 1 am exempt under Sec. I-- U B.BP.C. for this reason W Plan check fee . D D_. Date: !n _ PLUMBING PERMIT ISSUING FEE$ Z Signature- - Plan check applicant TOTAL FEE am iN& SINGLE FAMILY' , HOME OWNER-BUILDER DECLARATION Name - - - I hereby affirm that I am exempt from the Contractor's License Address Low for the following reason (Section 7031.5, Business and - - Professions Code): r City Tel. No. as owner of the property, will do the work and the structure is not intended or offered for sale (Section D 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 6 O 7.9 A I hereby affirm that there is a construction lending agency for ------ •- - -- -• ''' - ' the performance of the work for which this permit is issued _ _ _ _ _ '# s e e e,e 5 _ (Sec. 3097, Civ. C.). - - - I o.o3450 Lender's Name _.. _ _.. . .. --- -• --- . o . 34,505 Lender's Address - 1 certifythat I have read this application and state that the D 1 208-86 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_-_ ••; Srj6nature'o4 Term(tted D6to -. _ ...-_.- _ -_... -. . ,......... .-. _ _..- .._.,..__. r C WGRKFRS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING 0 0l�AIDIIaOrf� PERMIT I hefeby,affirm that I have a certificate of consent to self 76A667A - FOR Ir IL Y.ItYH910 Otl`L9 Ir KIK,H9, 0 insure, or o certificate of Workers' Compensation Insurance, CE 817 (REV.8/86) or a certified copy thereof (Sec. 3800, Lob. C.) - COUNTY OF LOS ANGELES DEPT.� OF PUBLIC WORKS ❑ollcy PNo. Company - Certified copy is hereby furnished. ❑ - FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec ADDRESS tion department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY Date Applicant WATER CLOSET NEAREST • CERTIFICATE OF EXEMPTION FROM WORKERS" BATHTUB - CROSS.ST. � COMPENSATION INSURANCEOWNER -� (This section nand not be completed if the work involved by SHOWER ' the permit Is for one hundred dollars($100)or less.) LAVATORY - '�'•`- `.� I certify that in the performance of the work for which this ADDRESS - - permit is issued, I sholl not employ any person in any manner SINK CITY . TEL. NO., so as to be ome fublect to the Worke i Compensation La DISHWASHER- e ,./� CONTRACTOR Dote �� Applicant �'-`-'�•'-¢ CLOTHES WASHER ADDRESS NOTICE tO APPLICANT: If, after rKalling This Certificate of IFSWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- CITY TEL. NO. •with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATE LIC. deemed revoked. WATE HEATER LICENSE NO. CLASS . LICENSED CONTRACTORS DECLARATION /, DISTRICT NOPR SSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS O'V 5 (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 - FINg? V LIDATION License Number Lic. Class-' DA i` () t FIN % 0 Contractor Dote BY f LU ❑ Iam exempt under Sec. 2 7 9 a 3 A a• B.BP.C. for this reason NPlan check fee 1 D # e e e e,e 5 ? Date: PLUMBING PERMIT ISSUING FEE E Signature 'il e e 3 a• 5.0 TOTAL FEE o -i- 3k505 Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that 1 am exempt from the Contractor's License Address - Low for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. U 9.2 3'`8 7 I, as owner of the property, will do the work and the - D structure is.not intended or offered for sale (Section 7044, 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 - 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 inspection purp es. ' ��j/��"� yMpA SEE REVERSE FOR EXPLANATORY LANGUAGE if g otµe o Permittee 1 Date/Ia - '