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Home My Public Portal About9450 BROADWAY_Plumbing__ WORKERS'COMPENSATION DECLARATION I APPLICATION FOR I�LAIICAIDIpIL}► PERMIT 1 hereby affirm that I have a certificate of consent to self 76A667A u u IL i`ri 0 11�7 Ir II•t PLUMBING OCI tI.Y If"IG II'lEH9 II insure, or.a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or o certified copy thereof (Sec. 3800, Lob, 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 q p Certified copy is Filed with the county building inspec- ADDRESS 7 ,SD QC•Cd Wa tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY ' Date Applicant WATER CLOSET •99t. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. r COMPENSATION INSURANCE SHOWER OWNER Cp"y glU1II&O (This section need not be completed if the work involved by hull the permit is for one hundred dollars ($100) or less.) s,)r LAVATORY �jr 3(.• '-" ADDRESS Oq�W,q I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK 6 CITY t°M Ze CI TEL. NO. 7 •_ 7 so as to become subject to the Workers'Compensation Lows. DISHWASHER ]f(.Lc{'LQ�(J�p�,' •O�rr•O Date 1-7-3,3 t •� 4j '� CONTRACTOR tC CG 7+� ApplicanCLOTHES WASHER NOTICE APPLICANT: If, after making this Certificate of ADDRESS 474 (.t/ Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY 1� D, & TEL. NO. with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATELIC. deemed revoked. WATER HEATER rQ0 / LICENSE NO. 7sj�J d C1A55 4- LICENSED CONTRACTORS DECLARATION CJ DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3.of the Business OUTLETS OVER -- -4 , and Professions Code,and my license is in full force and effect. 5 PER SYSTEM S FINAL VALIDATION O License Number N/634 Lic. Class C-3.G DATEIM 3•` •p,�' v •�,,, /J FINAL O Contractor//cJS1 16�a^ Date 1�Z F3 BY �7 u ❑ I am exempt under Sec. a N B.&P.C. for this reason D Z 9 ,� P� Plan check fee Date: SignaturesPLUMBING PERMIT ISSUING FEE$ ' �/al�^ TOTAL FEE "0 SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address r Low for the following reason (Section 7031.5, Business and U 9 C.2 A Professions Lode): City Tel. No. IDI, as owner of the property, will do the work and the 5 structure is not intended or offered for sale (Section D �'O 1 3250 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY .° ° 3 2 5 0 5 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 lows regulating Plumbing, and hereby' authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 0d2c 9- Z-R3 Signature of Permittee Dote WORKER'S that COMPENSATION DECLARATION 76A667DPW9189 APPLICATION FOR PLUMBING PERMIT 0-0026 I hereby affirm that I have a certificate of consent to self Insure, or a Certificate of Worker's Compensation Insurance, or a certified h ' coppyy� n rrreef(Sec.3800 Lab CJ PaTre�S+b.32Ct&&zS0ampany ��'�lf�'�C-P COUNTY OF LOS.ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. �❑ Certified copy is hereby furnished. 9P Certified copy is filed with the Co uiltling inspec n FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING z9^06 ADDRESS / / j�/� department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY L Date _// I Applicant �f 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($100)or less.) OWNER f I certify that in the performance of the work for which this permit LAVATORY is issued, I shall not employ any person in any manner so as to SINK MAIL became subject to the Workers'Compensation Laws. ADDRESS DISWASHER CITY TEL.NO. Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR G`n Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS �� - ��_ /� C provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM e_4 J LICENSED CONTRACTORS DECLARATION CIu�+(i TEty(N� t } I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER d (commencing with Section 7000) of Division 3 of the Business and .STATE LIQI 9/ 4U. �U GAS SYSTEM OUTLETS LICENSE NO. ��lG 7y- CLA J {o Professions Code,and my license is in full force and effect. U OUTLETS OVER DISTRICT NO. �p PROCESIEDIETENS / 5 PER SYSTEM D� f/ License Number\`Lia-0lass G 3 b _ — .. c c� �,1/ NA DATE i0 3 VAHWATION 40,,5a UJI Contract Date _LC/ U ❑ FINAL CHANGE .COLO I am exempt der Sec. BY B.BP.C.for this reason / Date: Plan check fee Signature PLUMBING PERMIT ISSUING FEE$ Gj LqOIJL 1 PM 1201,13 ❑ TOTAL FEE ,Q 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 Code): ❑ City Tel.No. I,as owner of the property,will do 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 Slate laws regulatinglumb ing, and hereby authorize repre fives of this Coun to enter upon the above-mentioned ' pi party for in pection purp es. SEE REVERSE FOR EXPLANATORY LANGUAGE -3 816natihe of Permittee Date r