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Home My Public Portal About9665 BROADWAY_Plumbing__ WORKER' COMPENSATION DECLARATION 76A66DPVJ 9/89 APPLICATION FOR PLUMBING PERMIT 0-00265 I herebIy affirm that I ;ave a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab. C.) - 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. : NUMBER • FIXTURE OR ITEM FEE LOCALITY Date Applicant (! WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE - / ASSESSOR }^�—Q� (This section need not be completed it the work involved by the 4 SHOWER MAP BOOK r-/J(ti PAGE I PARCEL permit is for one hundred dollars($100)or less.) OWNER (.certify that in the performance of the work for which.this permit LAVATORY is issued, I shall not employ any person in any manner so as toSINK MAIL become subject to the Workers:Compensation Laws. - - ADDRESS ��.�. ��.', DISWASHER CITY TEL.NO. Date_JL.1 Applicant � .t �r / CLOTHES WASHER NOTICE TO APPLICANT: if, after making this CeALJXato of CONTRACTOR riLet W! I. U� Exemption, you should became subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS provisions of the Labor Code, you must forthwith comply with such KJv RI" provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION - CITY TEL.NO. WATER HEATER �,�i0 a I hereby affirm that I am licensed under provisions of Chapter 9 STATE LIC. (commencing with Section ]000) of Division 3 of the Business and. pp Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. �� CLASS O' U OUTLETS OVER DISTRICT NO. y�/pgOCESSED BY Ir ' y r License Number 5 PER SYSTEM �(D v yid_��ItLL J Q ��P7 Lia Class Kms/ cJ O Gam!/! //,t/� / 1 ^W,,',�-` - FINAL VALIDATION t W ContractorAN�wiLi &-&r- W`^ Date , �V / v DATE 3,_2f/-f' ElaY I am exempt FINAL Z under Sec. BY _ BAP.C.for this reason ��- An:. r Plan check tee Date: _ Signature - PLUMBING PERMIT ISSUING FEE$ ' ❑ _ TOTAL FEE Q ;, T L!`j-. Plan check applicant SINGLE FAMILY HOMEOWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law F,-�k ,>•. 3.`i), _I 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 D - t--f_xj-aj't it_{;7 lj y`y1 and Professions Code). S CONSTRUCTION LENDING AGENCY - "' F' 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 authorize - representatives of this County to enter upon the above-mentioned prop erq for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE rLr. S. )01 4 L _ ... ... . Signature of Permitte a e ►WORKERS'COMPENSATION DECLARATION DPW APPLICATION FOR PLUMBING PERMIT I'hereby, affirm that I Workers' certificate of alioconsentsto self ina �6A6667A 4/87 sure,or a certificate of Workers'Compensation Insurance,ora CE 3I7(REV.B/86) - certified comy..thereof (Sec: 3800, Lab. C.) _ Policy N6.-Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Y F] Certified copy is hereby furnished. FOR APPLICANT 70 FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspection - ADDRESS department. ,. _ NUMBER .FIXTURE OR ITEM @ FEE - / �.�.w LOCALITY -r . Date Applicant WATER CLOSET(TOILET) w NEAREST / L CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.• / COMPENSATION INSURANCE SHOWER OWNER T 1 �� (This*section need not be completed if'the work involved by MAIL 1 the permit is for one hundred dollars ($100)or less.) LAVATORY - ADDRESS- A I certify that in the performance of the work for which this per. SINK mit is issued, I shall not employ any person in any manner so CITY � •�` TEL NO: as to become subject to the Workers Compen tion Laws. DISHWASHER 65 ./ypp_ 'CONTRALTO Date Applicon 1 1-4"`�`�w^' CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS SWIMMING POOL RECEPTOR emption,you should become subject to the Workers"Compen- CITY TEL. NO. cation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM _ .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 7010)of Division 3 of the Business OUTLETS OVER 5s and Professions Code, and my license 'Is in full force and ef- 5 PER SYSTEM FINALY fect. DATION 0a License Number Lic.'Class U FINAL W Contractor Date BY t O ✓ F OI am exempt under Sec. r, W a 8.8P.C. for this reason N Plan check fee _ 00 Date: PLUMBING PERMIT ISSUING FEE S O �Q Signature TOTAL FEE SINGLE FAMILY - 0 2 0 7 Q,3'A HOME OWNER-BUILDER DECLARATION Plan check applicant ' I hereby affirm that I am exempt from the Contractor's License Name t # Is a Is a Is 5 Law for the following reason (Section 7031.5, Business and ( • .� 2 a 5 Professions Code): Address XCity3 I, as owner of the property, will do the work and the Tel. No. e s a `Z 8,5 Q v iructure is not intended or offered for sale(Section 7044, _ Business and Professions Code). - " ' Poo. - - o 9.2 2�8 8 CONSTRUCTION LENDING AGENCY hereby affirm that there iz 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 applicationand state that the above information is correct. I agree to comply with all County - ► ordinances and State laws regulating Plumbing, and hereby au Lhorize representatives of this County to enter upon the a v me ed property for inspection purposes SEE[.��-/ SEE REVERSE FOR*IEXPLANATORY LANGUAGE ignature of Permittee Dote